Substance Abuse Treatment - Evaluation Report, OLA MN, 2006

Substance Abuse Treatment - Evaluation Report, OLA MN, 2006

• Feb. 25, 2016 • Locations: United States of America -> Minnesota • Topics: Corrections Audits, Drug Treatment/Rehab

Download original document:
Brief thumbnail

Document text

This text is machine-read, and may contain errors. Check the original document to verify accuracy.

OLA

OFFICE OF THE LEGISLATIVE AUDITOR
STATE OF MINNESOTA

EVALUATION REPORT

Substance Abuse
Treatment

FEBRUARY 2006

PROGRAM EVALUATION DIVISION
Centennial Building – Suite 140
658 Cedar Street – St. Paul, MN 55155
Telephone: 651-296-4708 ● Fax: 651-296-4712
E-mail: auditor@state.mn.us ● Web site: http://www.auditor.leg.state.mn.us

Program Evaluation Division

Evaluation Staff

The Program Evaluation Division was created
within the Office of the Legislative Auditor (OLA)
in 1975. The division’s mission, as set forth in law,
is to determine the degree to which state agencies
and programs are accomplishing their goals and
objectives and utilizing resources efficiently.

James Nobles, Legislative Auditor

Topics for evaluation are approved by the
Legislative Audit Commission (LAC), a
16-member joint, bipartisan commission. The
division’s reports, however, are solely the
responsibility of OLA. Findings, conclusions, and
recommendations do not necessarily reflect the
views of the LAC or any of its members.
A list of recent evaluations is on the last page of
this report. A more complete list is available at
OLA's website (www.auditor.leg.state.mn.us), as
are copies of evaluation reports.
The Office of the Legislative Auditor also includes
a Financial Audit Division, which annually
conducts an audit of the state’s financial statements,
an audit of federal funds administered by the state,
and approximately 40 audits of individual state
agencies, boards, and commissions. The division
also investigates allegations of improper actions by
state officials and employees.

Joel Alter
Valerie Bombach
David Chein
Jody Hauer
Adrienne Howard
Daniel Jacobson
Deborah Junod
Carrie Meyerhoff
John Patterson
Judith Randall
Jan Sandberg
Jo Vos
John Yunker
This document can be made available in alternative
formats, such as large print, Braille, or audio tape,
by calling 651-296-8976 Voice, or the Minnesota
Relay Service at 651-297-5353 or 1-800-627-3529.
E-mail: auditor@state.mn.us
Reports of the Office of the Legislative Auditor
are available at our web site:
http://www.auditor.leg.state.mn.us

Printed on Recycled Paper.

Photo Credits:
The photographs on the Substance Abuse Treatment report cover were provided courtesy of PDPhoto.org, flickr.com,
OHS Health and Safety Services, Inc., and St. Anthony’s Health Center.

OLA

OFFICE OF THE LEGISLATIVE AUDITOR

State of Minnesota • James Nobles, Legislative Auditor

February 2006
Members
Legislative Audit Commission
Substance abuse does great harm to individuals, families, and society. While some types of
treatment may mitigate the harm, research shows that not all treatment is effective.
Our evaluation found that Minnesota needs stronger leadership to help ensure that effective
treatments are more widely available. The Department of Human Services should foster the
development of effective treatment options, particularly in parts of the state that are
underserved. In addition, the department should more closely monitor local decisions that
place people in publicly-funded treatment to better ensure that appropriate services are being
used.
We found that many chemically dependent prisoners have not received any treatment during
or after their time in prison. Thus, we recommend that the Department of Corrections work
with the Legislature to develop more treatment opportunities for prisoners. We also
recommend that the department work with local corrections agencies to more effectively
plan for inmates’ post-prison treatment needs.
This report was researched and written by Joel Alter (project manager), Valerie Bombach,
and Kelly Lehr. During our evaluation, we received full cooperation from the Department
of Human Services, Department of Corrections, Department of Public Safety, Sentencing
Guidelines Commission, and county human services and corrections agencies.
Sincerely,

James Nobles
Legislative Auditor

Room 140 Centennial Building, 658 Cedar Street, St. Paul, Minnesota 55155-1603 • Tel: 651/296-4708 • Fax: 651/296-4712

E-mail: auditor@state.mn.us • TDD Relay: 651/297-5353 • Website: www.auditor.leg.state.mn.us

Table of Contents

Page
SUMMARY

INTRODUCTION

BACKGROUND
Key Terms
Community-Based Treatment in Minnesota
Prison-Based Treatment in Minnesota

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS
General Observations
Research on Community-Based Treatment
Research on Prison-Based Treatment

17
19

COMMUNITY-BASED TREATMENT: USE AND

AVAILABILITY
Department of Human Services’ Role
Counties’ Use of Substance Abuse Treatment
Chemical Use Assessments
Availability of Substance Abuse Treatment

COMMUNITY-BASED TREATMENT: OUTCOMES AND

PROGRAM OVERSIGHT
Addressing Individual Needs
Length of Treatment
Program Completion Rates
Readmissions to Treatment
External Reviews of Treatment Programs

78
81

TREATMENT FOR PRISONERS: USE AND AVAILABILITY
Assessment Practices
Participation in Treatment While in Prison
Participation in Treatment After Release From Prison

85
88

TREATMENT FOR PRISONERS: OUTCOMES
Program Completion Rates
Criminal Recidivism Following Treatment
Relapse Rates Following Release From Prison

100

108

LIST OF RECOMMENDATIONS

111

AGENCY RESPONSES

113

RECENT PROGRAM EVALUATIONS

117

List of Tables and Figures

Tables
1.1
1.2
1.3
1.4
1.5

Page

Definitions of Chemical Abuse and Dependency in Minnesota Rules
4

American Psychiatric Association Criteria for Substance Dependence
5

Services in Community-Based Treatment Programs
7

“Levels of Care” in Community-Based Substance Abuse Treatment
11

Characteristics of Persons Admitted to Community-Based Treatment,

1995 and 2004
12

1.6 Chemical Dependency Programs in Department of Corrections
Institutions, January 2006
14
2.1 National Institute on Drug Abuse’s “Principles of Effective Treatment” 23

3.1 Utilization of Publicly-Funded Treatment, 2003-04
38

3.2 Select Counties’ Treatment Referral Practices for Consolidated Chemical

Dependency Fund Clients, 2003-04
40

3.3 Required Topics for Consideration in Rule 25 Assessments
44

3.4 Local Corrections Directors’ Perceptions of Rule 25 Assessments
45

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

3.9 Local Corrections Directors’ Views Regarding Treatment Availability,

by Level of Care
56

3.10 Local Corrections Directors’ Views Regarding Treatment Availability

for Certain Offender Groups
57

3.11 Local Corrections Directors’ Views on the Availability of Treatment-

Related Services
60

3.12 Number of Counties with All Treatment Admissions Provided Outside

of Clients’ Counties of Residence, by Level of Care
61

3.13 Consolidated Chemical Dependency Treatment Fund Eligibility
63

4.1 Local Corrections Directors’ Preferences for Greater or Lesser Use

of Certain Treatment Approaches
73

4.2 Average Duration of Publicly-Funded Treatment for Treatment

“Completers,” 2004
74

4.3 Local Corrections Directors’ Preferences for Changes in Treatment

Program Duration
76

5.1 Projected Length of Prison Time for Persons Entering Prison, 2004
90

6.1 Client Completion Rates for Prison-Based Substance Abuse Programs,

2004
99

viii

SUBSTANCE ABUSE TREATMENT
6.2 Reoffense Rates of Chemically Dependent Prisoners Released in 2002
by Program Participation
104
6.3 Reoffense Rates of Chemically Dependent Prisoners Released in 2002,
by Gender and Age
107
6.4 Relapse Rates of Prisoners and Others Who Completed Substance
Abuse Programs in 2002
110
Figures
3.1 State Appropriations (in Millions) for Consolidated Chemical
Dependency Treatment Fund, FY 2000-06
3.2 Financial Responsibility for Publicly-Funded Substance Abuse
Treatment
4.1 Average Length (in Days) of Completed Treatment per Admission,
2000-04
4.2 Number of Prior Treatment Episodes for Persons Who Completed
Community-Based Treatment in 2004
4.3 Average Number of Violations per Licensed Program Reviewed,
2003-05
6.1 Recidivism Rates of Chemically Dependent Prisoners Released in
2002

64
65
75
80
84
102

Summary

Major Findings:
•

Stronger state
leadership and
oversight are
needed to
improve the
availability and
effectiveness of
substance abuse
treatment in
Minnesota.

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. (pp. 18
21)

•

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. (pp. 36, 46, 55-62)

•

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. (pp. 37-41)

•

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.
(pp. 92, 103-105)

•

Few inmates deemed chemically
dependent by prison staff enroll in
treatment upon release from prison,
which partly reflects inadequate
planning by state and local
corrections officials to address
inmates’ post-prison treatment needs.
(pp. 93-94)

Key Recommendations:
•

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. (pp. 50, 68, 69,
82)

•

The Department of Corrections
should (1) develop a strategy for
improving the post-release outcomes
of chemically dependent inmates
who do not complete treatment in
prison; (2) present the Legislature
with a plan for ensuring that more
offenders receive the treatment they
need during and after prison, and (3)
work with local agencies to improve
post-release substance abuse plans
for individual inmates. (pp. 95, 96,
108)

SUBSTANCE ABUSE TREATMENT

Report Summary

State policy
supports the use
of substance
abuse treatment,
although evidence
about treatment
outcomes is
limited.

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
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.

Effectiveness Studies Show Mixed
Results, And Information On
Minnesota’s Community Programs
Is Limited
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

Minnesota Statutes 2005, 254A.01.

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.

SUMMARY

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.

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.

Use Of Community-Based
Treatment Reflects Significant
Variation In Program Availability
And Local Referral Practices
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.
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’

xii

SUBSTANCE ABUSE TREATMENT

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.

Prisons Need More Treatment
Beds And Better Planning For
Services Following Release

Most chemically
dependent
inmates do not
complete
treatment in
prison or when
they are released.

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.
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.

Introduction

buse of alcohol and other drugs has widespread impacts. It often leads to
reduced personal productivity, harmful health effects, and damaged personal
relationships. 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 provide
chemically dependent people with rehabilitative services.1
But policy makers have asked many questions about substance abuse treatment in
recent years. In April 2005, the Legislative Audit Commission directed our
office to evaluate substance abuse treatment in Minnesota communities and state
prisons. Our evaluation addressed the following questions:
•

Are substance abuse treatment programs effective?

•

Is there adequate treatment for chemically dependent criminal
offenders sentenced to prison and probation?

•

To what extent do counties vary in how they assess and refer
individuals to community-based substance abuse treatment, and
should 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, and
Public Safety to assess outcomes for persons who entered treatment programs.
For example, we examined the extent to which chemically dependent inmates
who participated in prison-based treatment programs were arrested and convicted
of new crimes following release from prison. For community-based treatment,
we examined measures such as program completion rates and rates of
readmission to treatment following treatment discharge. We recognize that
factors other than treatment may have contributed to the outcomes we observed,
so we also examined findings from previous studies of substance abuse
treatment.2
We looked at treatment use and availability in Minnesota, including variation
among counties. Local human services agencies play a key role in treatment
1
2

Minnesota Statutes 2004, 254A.01.

We did not conduct “experimental” research, in which persons are randomly assigned to various
programs or to no treatment at all. Such studies provide more definitive evidence of treatment’s
impacts.

SUBSTANCE ABUSE TREATMENT
placement decisions, and we conducted site visits to eight counties and contacted
some others by phone.3 Publicly-funded treatment for low-income persons
accounts for more than half of Minnesota’s substance abuse treatment
admissions, so we gave particular attention to its use. We looked at variation
among counties in the share of treatment costs they bear, but we did not conduct
an in-depth evaluation of the formula used to allocate state treatment funds to
counties.
Because of the close association between substance use and crime, we also
looked at treatment availability and use among Minnesota’s criminal offenders.
Specifically, we examined the extent to which chemically dependent offenders
enrolled in treatment programs in prison, after prison, and during probation.
Community-based corrections agencies supervise many offenders with substance
abuse problems, so we conducted a statewide survey of the directors of these
agencies to better understand their perceptions about treatment availability and
adequacy.4
Chapter 1 provides background information on substance abuse treatment
services in Minnesota communities and prisons. Chapter 2 reviews previous
research on treatment effectiveness. The next two chapters examine communitybased treatment in Minnesota, including client placements (Chapter 3) and
certain treatment outcomes (Chapter 4). The final two chapters examine prisonbased treatment, including availability (Chapter 5) and rates of post-prison
recidivism and relapse (Chapter 6).
Finally, we often use the terms “substance abuse” and “chemical dependency”
interchangeably in this report. Chapter 1 notes the diagnostic distinctions
between “abuse” and “dependency,” and Chapter 3 examines differences among
counties in their diagnoses, but elsewhere in the report we do not differentiate
between “substances” and “chemicals” or between “abuse” and “dependency.”

We did not review individual clients’ case files during our site visits, such as assessment reports
or treatment plans.

To provide probation services, each Minnesota county (1) participates in the state’s Community
Corrections Act (CCA) and receives state funds for this purpose, (2) receives “county probation
officer” (CPO) funding from the state, or (3) obtains services from the Minnesota Department of
Corrections (DOC). We surveyed and received responses from all of the 54 directors of CCA
agencies, CPO agencies, and DOC’s district offices and supervised release offices.

Background

SUMMARY

Minnesota law supports treatment and other rehabilitative services for
people with substance abuse problems. The state has provided significant
funding for community-based treatment for low income persons, as well as
funding for substance abuse programs in most of the state-operated
prisons. Current state rules that define chemical “dependency” do not
reflect diagnostic criteria commonly used by mental health professionals,
although changes to the outdated definition are scheduled for
implementation in 2007. Alcohol remains the predominant substance
abused by people entering treatment in Minnesota, but the number of
people entering treatment for methamphetamine use grew dramatically
during the past decade.

variety of factors contribute to chemical dependency, including social
influences, genetic predispositions, the nature and availability of the
substances abused, and underlying psychological disorders.1 Substance abuse
involves voluntary behaviors, at least initially, but it may also evolve into
compulsions and loss of control. Substance abuse treatment takes many forms,
and relapses are common. This chapter provides background information on
substance abuse treatment, and it addresses the following questions:
•

How are substance “abuse” and “dependency” defined?

•

What types of treatment programs are offered in community-based
and prison-based settings?

•

What roles do Minnesota’s state and local governments play in
overseeing substance abuse treatment programs, paying for
treatment, and helping individuals access treatment services?

•

What are the primary substances abused by persons entering
treatment, and how has this changed in recent years?

KEY TERMS
Substance “Abuse” and “Dependency”
Definitions of chemical “abuse” and “dependency” are important because
Minnesota’s administrative rules prescribe the types of publicly-funded treatment
for which persons are eligible, based partly on whether the person is determined
1

George E. Vaillant, “Natural History of Addiction and Pathways to Recovery,” in Principles of
Addiction Medicine, 2nd ed., ed. Allan W. Graham and Terry K. Schultz (Chevy Chase, MD:
American Society of Addiction Medicine, 1998), 295-308.

SUBSTANCE ABUSE TREATMENT
to be chemically dependent rather than chemically abusive.2 As shown in Table
1.1, the rules define chemical abuse as less severe than chemical dependency.3
We found that:
•

Minnesota’s criteria for determining who is “chemically dependent”
are not consistent with current professional criteria for diagnosing
mental health disorders.

The Minnesota rules that define “abuse” and “dependency” are based on the 1980
edition of the American Psychiatric Association’s Diagnostic Statistical
Manual.4 The rules require that dependency be based, in part, on evidence of

Table 1.1: Definitions of Chemical Abuse and
Dependency in Minnesota Rules
State
administrative
rules define
substance
“abuse” and
“dependency.”

Chemical abuse is a pattern of inappropriate and harmful chemical use which exceeds
social or legal standards of acceptability, the outcome of which is characterized by three
or 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 financial
obligations.
Loss of friends due to behavior while intoxicated.
Chemical use that prohibits one from meeting work, school, family, or social
obligations.
Continued use of chemicals by a woman after she has been informed that she is
pregnant and that continued use may harm her unborn child.

Chemical dependency is a pattern of pathological use accompanied by the physical
manifestations of increased tolerance to the chemical or chemicals being used or
withdrawal syndrome following cessation of chemical use. “Pathological use” means the
compulsive 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 days
at a time.
Amnesic periods for events occurring while intoxicated.
Continuing use despite a serious physical disorder that the individual knows is
exacerbated by continued use.
Continued use of chemicals by a woman after she has been informed that she is
pregnant and that continued use may harm her unborn child.

SOURCE: Minnesota Rules 2005, 9530.6605, subp. 6, 7, 18, and 20.

For example, the rules specify that inpatient (or “primary rehabilitation”) treatment may be used
only for persons assessed to be chemically dependent. In contrast, outpatient treatment may be
used for persons who are either chemically dependent or chemically abusive.

In Minnesota rules, chemical “dependency” is defined as involving a “pattern of pathological
use,” while chemical “abuse” has no such pattern.

4
The Diagnostic Statistical Manual has the most widely used criteria in the United States for
determining psychiatric disorders.

BACKGROUND

5
physical tolerance of a chemical or physical withdrawal symptoms following
cessation of chemical use. But, since 1987, the Diagnostic Statistical Manual
has treated physical tolerance and withdrawal as no different from other
symptoms that can characterize “dependence.” As shown in Table 1.2, the
manual now regards physical, psychological, and behavioral symptoms of
dependency in a balanced way, rather than emphasizing physical symptoms.5
Unlike current mental health criteria, Minnesota rules still require evidence of
physical dependency to make a diagnosis of chemical dependency. Thus,
Minnesota’s criteria to determine eligibility for particular types of publiclyfunded treatment are not consistent with the most widely recognized diagnostic
standards in the substance abuse profession.

In recent years,
Minnesota’s
criteria for
identifying
chemical
dependency
differed from
accepted
professional
standards.

The Minnesota Department of Human Services (DHS) has been drafting
revisions to the rules that govern chemical use assessments, with the intention of
implementing new rules on January 1, 2007. The most recent draft states that, to
qualify for treatment, individuals must meet the criteria for “substance use

Table 1.2: American Psychiatric Association Criteria
for Substance Dependence
Substance dependence is a maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by three or more of the following
indicators, occurring at any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
• A need for markedly increased amounts of the substance to achieve
intoxication or desired effect.
• Markedly diminished effect with continued use of the same amount of the
substance.
2. Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for the substance.
• The same (or a closely related) substance is taken to relieve or avoid
symptoms.
3. The substance is often taken in larger amounts or over a longer period than
was intended.
4. The person experiences a persistent desire (or unsuccessful efforts) to reduce
or control substance use.
5. A great deal of time is spent in activities necessary to obtain the substance
(e.g., visiting multiple doctors or driving long distances), use the substance, or
recover from its effects.
6. Important social, occupational, or recreational activities are given up or
reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused
or exacerbated by the substance (e.g., current cocaine use despite recognition
of cocaine-induced depression, or continued drinking despite recognition that
an ulcer was made worse by alcohol consumption).
SOURCE: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders,
th
4 ed., Text Revision (Washington, D.C.: American Psychiatric Publishing, 2000).

5
Samuel A. Ball and Therese A. Kosten, “Diagnostic Classification Systems,” in Principles of
Addiction Medicine, 2nd ed., 280.

SUBSTANCE ABUSE TREATMENT
disorder” in the current version of the Diagnostic Statistical Manual.6 The draft
rules, if adopted, would eliminate the outdated definitions of “dependency” and
“abuse” that are still being used.

Substance-Related “Treatment”
State administrative rules define “treatment” as:
[A] process of assessment of a client’s needs, development of planned
interventions or services to address those needs, provision of services,
facilitation of services provided by other service providers, and
reassessment. The goal of treatment is to assist or support the client’s
efforts to alter the client’s harmful pattern of chemical use.7

Minnesota has
about 300 statelicensed treatment
programs.

There are about 300 substance abuse treatment programs licensed by the
Department of Human Services. Table 1.3 shows services that licensed treatment
programs must provide, as well as several “optional” services. Treatment
programs also employ a variety of treatment approaches and philosophies. For
example, the widely-referenced “Minnesota model” of treatment incorporates the
“12 steps” of Alcoholics Anonymous (AA) and views substance abuse as
resulting from underlying biological or psychological vulnerabilities.8 In
contrast, some treatment approaches start with the assumption that substance
abuse is a learned, maladaptive behavior and aim to change clients’ distorted
thinking about substance use.9 In addition, treatment programs have varying
goals. Some programs view total abstinence from alcohol and drugs as an
essential part of recovery, while other programs emphasize reduced
consumption.10
Unfortunately, there is no systematic, statewide inventory of the types of
treatment approaches used by various programs, or the extent to which the
programs offer the optional services listed in Table 1.3. Thus, it is hard to
characterize which approaches and services are the most common. DHS staff
told us that they used to produce a statewide program directory but stopped
because the information was self-reported by treatment providers and considered
to be of limited value.11 However, some county officials told us that a statewide
6

Department of Human Services, “Proposed Permanent Rules Relating to Chemical Dependency
Treatment,” July 31, 2004.

Minnesota Rules 2005, 9530.6405, subp. 19.

Unlike Alcoholics Anonymous self-help groups, “Minnesota Model” treatment programs are
professionally directed.
9

Paige Crosby Ouimette, John W. Finney, and Rudolf H. Moos, “Twelve-Step and CognitiveBehavioral Treatment for Substance Abuse: A Comparison of Treatment Effectiveness,” Journal
of Consulting and Clinical Psychology 65, no. 2 (1997): 230-240.

Medications may also be an important part of a client’s substance abuse treatment. For example,
there are medications that reduce cravings, discourage alcohol use, or address psychiatric disorders.
But, while treatment programs may administer medications that have been prescribed by a
physician (if properly staffed to do so), program staff are not permitted to prescribe medications.
11

In response to our request for information about the nature of Minnesota’s treatment programs,
DHS provided us with the brief descriptions of chemical dependency programs from
MinnesotaHelp, an online database intended to help consumers locate social services agencies near
their homes. The database is sponsored by DHS and several other agencies. The program
descriptions in MinnesotaHelp varied considerably in their scope and level of detail.

BACKGROUND

Table 1.3: Services in Community-Based Treatment
Programs
Mandatory Services

Optional Services

• Individual and group counseling

• Case management services

• Client education (e.g., regarding health
impacts of chemical use and ways to
avoid inappropriate chemical use)

• Relationship counseling

• “Transition services” (e.g., to help
clients integrate lessons learned in
treatment into daily living)

• Stress management

• Services to address issues related to
co-occurring mental illness

• Therapeutic recreation
• Living skills development
• Employment or educational services
• Socialization skills development
• Room, board, and supervision
provided at the treatment site

SOURCE: Minnesota Rules 2005, 9530.6430, subp. 1 and 2.

inventory would be a helpful tool for their staff to consult when making
treatment placements. In Chapter 3, we recommend the development of a
statewide program inventory, partly to provide local agencies and the general
public with more consistent information as they choose from among the various
programs. Also, an inventory could help state and county agencies exercise
program oversight, by helping to identify gaps in services or differentiating
programs when analyzing client outcomes.

COMMUNITY-BASED TREATMENT IN
MINNESOTA

State law supports
treatment for
persons who are
chemically
dependent.

In this report, we use the term “community-based treatment” to refer to all
substance abuse treatment programs that are licensed by DHS. State law requires
DHS to license programs that provide services such as care, supervision, and
rehabilitation outside of a person’s home.12 Minnesota’s licensed programs serve
a mix of privately- and publicly-funded clients in residential and non-residential
settings.

State Policy
Minnesota law establishes a policy that supports treatment and other services for
persons who are chemically dependent. Specifically, the law says:

Minnesota Statutes 2004, 245A.02, subd. 10 and 14. DHS licenses the treatment programs
offered in some of Minnesota’s local jails, but it does not license programs in Minnesota’s state
prisons (discussed later in this chapter). Programs in the community that provide exclusively
detoxification services are licensed by DHS separately from treatment programs and were not a part
of our review.

SUBSTANCE ABUSE TREATMENT
It is hereby declared to be the public policy of this state that the interests
of society are best served by providing persons who are dependent upon
alcohol or other drugs with a comprehensive range of rehabilitative and
social services.13
Furthermore, the law states that: (1) treatment should be voluntary when
possible; (2) treatment may not be denied on the basis of prior treatment; (3)
treatment must be based on individualized treatment plans; (4) there must be a
continuum of services available for persons leaving treatment programs; and (5)
treatment must include all family members at the earliest possible phase of the
treatment process.14
The emphasis of these policies on treating and providing services to substance
abusers is balanced in the law by criminal penalties for the sale, possession, and
manufacture of “controlled substances,” as well as driving under the influence of
alcohol or “controlled substances.”15 However, Minnesota’s criminal statutes
also address treatment, by requiring probation agencies to give judges
information about certain offenders’ treatment needs before the offenders are
sentenced.16

State Oversight

The Department
of Human
Services oversees
community-based
substance abuse
treatment
services.

Minnesota law assigns the Department of Human Services primary
administrative responsibility for the state’s community-based substance abuse
services.17 For example, the law requires DHS to coordinate and review state
agencies’ activities related to substance abuse problems. DHS must prepare a
state plan that sets goals and priorities for chemical dependency treatment, and it
must prepare biennial reports for the Governor and Legislature that address
service coordination, quality, duplication, and cost.18
DHS also has statutory responsibility to monitor the delivery of chemical
dependency services. The law requires DHS to collect information regarding
treatment programs’ efficiency and effectiveness, and DHS must monitor the
services that lead to client diagnosis and referral. DHS licenses treatment
programs and develops the administrative rules that govern client placement and
treatment.
In addition, DHS is required by law to monitor, conduct, and foster research
related to chemical dependency services. The department must inform the
general public about chemical use problems, and it must develop and disseminate
new methods of treating chemical dependency.
13

Minnesota Statutes 2004, 254A.01.

Ibid.

Minnesota Statutes 2004, 152.021-152.027 and chapter 169A.

Minnesota Statutes 2004, 609.115, subd. 8.

In particular, see Minnesota Statutes 2004, 254A.03, subd. 1.

DHS has periodically prepared statewide chemical dependency strategic plans. However, DHS
has not reviewed the consistency of other state agencies’ plans and budgets with its own goals and
priorities, contrary to the law’s requirements.

BACKGROUND

9
Finally, state law assigns fiscal responsibilities to DHS. For example, the
department administers state and federal funding for chemical use programs, and
it trains local agencies on procedures for handling payments.

Funding
More than half of
Minnesota’s
treatment
admissions are
publicly funded,
mostly with state
funds.

Minnesota’s main mechanism for providing publicly-funded substance abuse
treatment to low income persons is the Consolidated Chemical Dependency
Treatment Fund (CCDTF), created by the 1986 Legislature.19 This fund
combines state and federal resources to pay for treatment of persons who meet
financial and clinical eligibility criteria. A complex statutory formula specifies
how CCDTF funds are allocated among county and American Indian tribal
agencies. Also, state law requires counties to pay for a portion of the cost of
CCDTF-funded treatment, as we describe in more detail in Chapter 3.20
Treatment programs are eligible to receive payment from CCDTF if they have a
contract with a “host county” that includes a negotiated rate of payment for
publicly-funded clients.21
We analyzed records on Minnesota treatment admissions22 submitted to DHS by
treatment providers and found that:
•

About 44 percent of admissions of Minnesota residents to substance
abuse treatment programs in 2004 were funded by the state’s
Consolidated Chemical Dependency Treatment Fund.

In addition, 11 percent of admissions were funded by prepaid health care plans
that contract with the Minnesota Department of Human Services to serve persons
enrolled in Medical Assistance, General Assistance Medical Care, and
MinnesotaCare. The remaining 45 percent of admissions were paid by clients
themselves or by their private health insurance.23
The Department of Human Services estimates that CCDTF payments to
substance abuse treatment providers in fiscal year 2005 totaled $93.2 million, and
payments to counties for related administrative costs totaled another $1.7 million.
The state’s share of these costs was $62.0 million (65 percent), and the counties’
share was $17.3 million (18 percent).24

Laws of Minnesota 1986, chapter 394.

Minnesota Statutes 2004, 254B.02.

Minnesota Statutes 2004, 254B.03, subd. 1(b), requires that county boards, with the approval of
the DHS commissioner, “select eligible vendors of chemical dependency services who can provide
economical and appropriate treatment.”
22

Individuals sometimes have more than one admission during an “episode” of treatment, perhaps
as part of a planned sequence of care. In addition, an individual may have multiple admissions to
treatment over longer periods of time. Generally, an admission occurs when a client starts a new
program, even if this occurs immediately after transferring from another one.
23
24

The percentages presented here are based solely on Minnesota residents who entered treatment.

Federal funds, MinnesotaCare reimbursements, and other sources paid for the remaining $15.5
million of CCDTF expenditures.

SUBSTANCE ABUSE TREATMENT
Block grants authorized by the state’s Children and Community Services Act
provide another source of state funding that counties can use for a variety of
social services, such as chemical use assessments. Counties must submit biennial
service plans to DHS to receive these funds.25

Client Assessment and Referral

County agencies
assess and refer
most publiclyfunded clients.

State law requires county human services agencies to “provide chemical
dependency services to persons residing within [their] jurisdiction who meet
criteria established by the [Department of Human Services].”26 Also, state rules
require chemical use assessments of persons seeking publicly-funded treatment
for chemical abuse or dependency (or for whom such treatment is sought).27
County agencies conduct most of these assessments. In addition, organizations
that contract with DHS to provide prepaid health care funded by Medical
Assistance or General Assistance are required to assess their own enrollees, and
tribal governments have contracts with DHS that require them to offer chemical
use assessments to tribal members.28
Assessments conducted by counties, tribes, or prepaid public health plans must
(1) rate a client’s level of chemical involvement, and (2) use criteria in state rules
to refer the client to the appropriate type of program. Clients may be referred to
the types of programs shown in Table 1.4.

Treatment Trends
Data on all publicly- or privately-funded admissions to chemical dependency
treatment programs show that:
•

In recent years, there has been growth in Minnesota’s number of
chemical dependency treatment admissions, more reliance on
outpatient care, and some decline in alcohol’s longstanding
prevalence as the most common substance abused.

The number of admissions of Minnesota residents to the state’s chemical
dependency treatment programs increased from 32,292 in 1995 to 41,519 in
2004, a 29 percent increase. In addition, the number of Minnesota residents who
entered at least one treatment program during a given year grew from 26,080 in
1995 to 33,383 in 2004, a 28 percent increase.29 During the 1995-2004 period,
the state’s population increased 11 percent.

Minnesota Statutes 2004, 256M.30.
Minnesota Statutes 2004, 254B.03, subd. 1.
27
Minnesota Rules 2005, 9530.6610, subp. 1. This is part of what is often referred to as “Rule 25.”
Minnesota Statutes 2004, 169A.70 has separate provisions that require chemical use assessments of
persons convicted of impaired driving. The law requires these assessments to use the Rule 25
placement criteria, but the assessment forms are developed by and reported to the Department of
Public Safety. Also, Minnesota Statutes 2004, 169A.284 requires persons convicted of impaired
driving to pay a surcharge to help offset county assessment costs.
26

28
29

Some prepaid health plans contract with county agencies to conduct their assessments.

This is based on the unduplicated number of individuals entering treatment in a given year. The
other analyses in this section are based on all admissions to treatment during the time period.

BACKGROUND

Table 1.4: “Levels of Care” in Community-Based
Substance Abuse Treatment
Inpatient treatment (or “primary rehabilitation”): A residential program that provides
intensive therapeutic services following detoxification. Provides at least 30 hours a week
of services for each individual.
Outpatient treatment: A non-residential program that provides primary (or post-primary)
health care with a defined regimen for five or more individuals at a time who have
chemical use problems. Provides at least ten hours of total service time and must provide
time-limited therapeutic services.
Halfway house: A residential program that offers treatment, aftercare, community
ancillary services, and help in securing employment. Provides at least five hours a week
of rehabilitative services.
Extended care: A residential, long-term program that combines in-house chemical
dependency treatment and community-based ancillary resources. Provides at least 15
hours a week of chemical dependency services, which may include counseling, education,
and other rehabilitative services.
NOTE: The rules also specify a category called “combination inpatient/outpatient treatment” meaning
inpatient primary rehabilitation of 7 to 14 days, followed by outpatient treatment of three weeks or
more. However, this category is rarely used by treatment providers to categorize their admissions in
the data they report to DHS. Detoxification facilities are not considered to be treatment programs.

Outpatient
treatment
accounted for 53
percent of
admissions to
community-based
treatment in 2004.

SOURCE: Minnesota Rules 2005, 9530.6605.

Table 1.5 shows how the characteristics of admissions to treatment among
Minnesota residents in 1995 compared with those in 2004. Outpatient treatment
accounted for 53 percent of the state’s admissions in 2004, up from 48 percent in
1995. Meanwhile, the percentage of admissions to inpatient treatment and
halfway houses declined during this period.
Alcohol has been, and remains, the predominant substance abused by persons
admitted to treatment. However, cases in which alcohol was the primary
substance abused have comprised a declining percentage of admissions. The
percentage of admissions that were primarily due to methamphetamine use
increased dramatically during this ten-year period, from 2.4 percent of
admissions to 13.5 percent of admissions.

PRISON-BASED TREATMENT IN
MINNESOTA
Offenses related to substance abuse are a large and growing part of Minnesota’s
criminal justice system. Between 2001 and 2004, the number of offenders
sentenced in Minnesota for felony-level drug offenses grew by 56 percent.30 For
methamphetamine offenses alone, the number of persons sentenced for felonies

Minnesota Sentencing Guidelines Commission, Sentencing Practices, Controlled Substance
Offenses: Offenders Sentenced in 2004 (St. Paul, October 2005), 3. The number sentenced was
2,596 in 2001, 3,424 in 2002, 3,896 in 2003, and 4,038 in 2004.

SUBSTANCE ABUSE TREATMENT

Table 1.5: Characteristics of Persons Admitted to
Community-Based Treatment, 1995 and 2004
Client or Treatment Characteristic

Alcohol is the
predominant
substance abused
by persons
admitted to
community-based
treatment.

Percentage of Admissions to
Substance Abuse Treatment in:
1995

2004

Level of Care
Inpatient treatment
Outpatient treatment
Halfway house
Extended care

33.9%
47.5
11.1
5.5

30.7%
52.9
9.9
5.3

Gender
Male
Female

70.3
29.7

67.7
32.3

Age
Under 18
18-65
Over 65

9.5
88.9
1.6

10.6
88.5
0.9

Education Level
Did not complete high school
High school graduate or GED
Some college, but not a four-year degree
College graduate
Graduate or professional degree

32.4
49.3
11.1
5.5
1.7

32.2

50.2

10.6

5.5

1.5

Primary Substance Abuse Problem
Alcohol
Marijuana/hashish
Methamphetamine
Crack cocaine
Powder cocaine
Heroin

64.9
16.6
2.4
10.2
2.4
1.3

50.5

19.9

13.5

7.3

2.7

2.3

SOURCE: Office of the Legislative Auditor’s analysis of Department of Human Services’ Drug and
Alcohol Normative Evaluation System data. The analysis shown here includes only persons who
were Minnesota residents. Some totals do not add to 100 percent because certain categories were
excluded from the table.

during this period increased by 132 percent.31 Many of Minnesota’s criminal
offenders with substance abuse problems are sentenced to probation in the
community and could be referred to treatment in the community-based programs
discussed in the previous section. But offenders convicted of more serious
offenses or with longer criminal histories can be sentenced to prison, and we
found that:
31

Ibid., 4.

BACKGROUND

13
•

The number of offenders in Minnesota prisons for substance-related
offenses has increased significantly.

There was a 689 percent increase between 1990 and 2004 in the number of
persons in prison for drug offenses (from 276 to 2,178).32 Drug offenders now
comprise 25 percent of Minnesota’s prison population, up from 9 percent in
1990. The increase in drug offenders in prison partly reflects stricter sentences.
For example, the percentage of persons convicted of drug-related felonies who
were sentenced to prison was 25 percent in 2004, up from 12 percent in 1990.33

State law directs
the Department of
Corrections to
provide
“rehabilitative
programs” for
prison inmates.

State law requires the Commissioner of Corrections to provide “rehabilitative
programs” for prison inmates “within the limitations imposed by the funds
appropriated for such programs.”34 The Department of Corrections’ fiscal year
2006 budget for chemical dependency services is $3.6 million, including $3.3
million from state funding. In previous years, the department did not track
spending for chemical dependency services separately from other types of prisonbased treatment, so we were unable to measure spending trends.
Minnesota has eight state prisons for adults, and all but the Oak Park Heights and
Rush City prisons presently have a treatment or educational program related to
substance abuse.35 In addition, the two state-run correctional institutions for
juveniles each have substance abuse programs. Table 1.6 lists the programs in
Minnesota’s correctional facilities, as of January 2006. The prison-based
treatment programs generally take 6 to 12 months to complete, while the
substance abuse education programs (which are not considered to be “treatment”)
cover less material and last 3 months or less. The substance abuse treatment and
education programs both have group counseling sessions, but only the treatment
programs offer individual counseling. The Lino Lakes prison offers “aftercare”
programs for inmates who have completed a prison-based substance abuse
program.
There are more similarities than differences among the prison-based treatment
programs in Minnesota. All of the programs use a curriculum specifically
targeted to a population of chemically dependent criminal offenders. The
programs aim to get offenders to understand the progression of behaviors and

Minnesota Department of Corrections, based on July 1 prison populations each year. The
number of drug offenders in prison more than doubled between July 2000 and July 2005 (1,006 to
2,178).
33

Minnesota Sentencing Guidelines Commission, Sentencing Practices, Controlled Substance
Offenses: Offenders Sentenced in 2004, 8. The imprisonment rate for drug cases reached a high of
28 percent in 2003 before dropping to 25 percent in 2004. By comparison, the imprisonment rate
for non-drug felonies was 23 percent in both 2003 and 2004.
34
35

Minnesota Statutes 2004, 244.03.

Prison-based treatment programs are subject to slightly different standards than communitybased treatment programs. Minnesota Statutes 2004, 241.021, subd. 4a., says that if the
commissioners of Corrections and Human Services agree that the human services licensing rules
cannot “reasonably apply” to prison-based programs, then “alternative equivalent standards” shall
be developed by these agencies through interagency agreement.

SUBSTANCE ABUSE TREATMENT

Table 1.6: Chemical Dependency Programs in
Department of Corrections Institutions, January 2006
Correctional Institution

Program Name/Description

Number of
Beds or
Slots

Treatment Programs

Most of
Minnesota’s staterun correctional
facilities have
substance abuse
treatment or
education
programs.

Lino Lakes—Adult men

Treatment intake/orientation

10-20

Lino Lakes—Adult men

“TRIAD” long-term treatment

Lino Lakes—Adult men

“TRIAD” medium-term treatment

Lino Lakes—Adult men

“TRIAD” mental illness/chemical
dependency dual diagnosis treatment

“TRIAD” treatment for prisoners with
special needs

Sex Offender Treatment Program
(medium- and long-term treatment)

Stillwater—Adult men

“Atlantis” medium-term treatment

St. Cloud—Adult men

“Reshape” medium-term treatment

Shakopee—Adult women

“Changing Paths” medium-term treatment

Willow River—Adult men

“Challenge Incarceration Program”
medium-term treatment

“New Freedom” medium-term treatment

Lino Lakes—Adult men
Lino Lakes—Adult men

Thistledew—Adult women
Red Wing—Juvenile boys

518-528
Psycho-Educational Programs
Lino Lakes—Adult men

Short-term psycho-educational program

Faribault—Adult men

Short-term psycho-educational program

106

Thistledew—Juvenile boys

Short-term psycho-educational program
focused on methamphetamine addiction

12
193

In-Prison Aftercare Programs
Lino Lakes—Adult men

Various aftercare programs

175

SOURCE: Minnesota Department of Corrections.

thinking patterns that lead to criminality and addiction. In each of Minnesota’s
prison-based treatment programs, the program participants live together in
separate residential units of their prisons, known as “therapeutic communities.”
The most distinctive of Minnesota’s prison-based treatment programs is the
Challenge Incarceration Program (CIP) at the Willow River and Thistledew
facilities. While inmates in the other correctional facilities are “directed” by
prison staff to participate in treatment (and can be sanctioned if they do not),
inmates apply to participate in the CIP program. The program’s first six months
occur in a boot camp environment, and participants who successfully complete

BACKGROUND

15
this first program phase may be eligible for early release from prison. In
subsequent phases of CIP, participants remain under correctional supervision in
the community following their release from prison.36

Several prisons
will add chemical
dependency
treatment beds in
2006 or 2007.

Several of the other prison-based programs have unique elements. A chemical
dependency treatment program at the Lino Lakes prison is specifically designed
for sex offenders. Participants in this program complete a chemical dependency
treatment curriculum before starting a sex offender treatment curriculum. A
second Lino Lakes program focuses on inmates with “special needs,” such as
persons with brain injuries or developmental disabilities, and another Lino Lakes
program focuses on inmates who have dual diagnoses of chemical dependency
and mental illness.
The Department of Corrections intends to add treatment beds at several prisons
during 2006 and 2007. The largest addition will be 90 new beds at the Challenge
Incarceration Program in Willow River. Also, the department plans to add 12
beds to its Stillwater program and start a 24-bed program for adults at the Moose
Lake portion of the Moose Lake/Willow River institution. The department also
plans to start a 50-bed sex offender treatment program at the Rush City prison
that will include a chemical dependency treatment component.37

According to Minnesota Statutes 2004, 244.172, the second phase of CIP (following release from
prison) consists of at least six months of intensive supervision, and the third phase lasts until the
Commissioner of Corrections determines that the offender has successfully completed the program
or the offender’s sentence expires (whichever comes first).
37

In addition, the department uses a private correctional facility in Minnesota for some of its
inmates, and this facility plans to add a 25-bed chemical dependency treatment program during
2006.

Previous Research on
Treatment Effectiveness
SUMMARY

Research examining the effectiveness of substance abuse treatment has
yielded mixed results. Careful studies have shown that certain types of
treatment have better client outcomes, on average, compared with other
types of treatment or no treatment at all. For example, studies have yielded
positive findings, on average, for “brief interventions” with problem
drinkers, methadone maintenance programs, and certain “psychosocial”
treatment programs. Also, there is an emerging consensus that many
chemically dependent clients need extended periods of services, even if this
includes some low-intensity treatment or monitoring. But there is still
much to learn about what types of treatment work best in particular
circumstances. Even the more effective treatments do not succeed with all
clients, and there is limited evidence on the effectiveness of some common
programs.

tudies that rigorously examine the impact of treatment often require extended
periods of time to complete, including time to track participants’ outcomes
following treatment. Also, some of the better studies involve random assignment
of individuals to programs. We could not complete such a study, so this chapter
addresses the following questions:
•

What has research indicated about the overall effectiveness of
substance abuse treatment? Does research show that certain types
of treatment are more effective than others?

•

What have researchers concluded about the appropriate length of
treatment, the appropriate setting for treatment (such as inpatient or
outpatient), and the impact of treatment on drug court participants?

The research findings discussed in this chapter are based primarily on the results
of studies from academic, professional, and government publications. Most of
these studies did not evaluate Minnesota programs, but we think their findings
are pertinent to Minnesota’s policy makers and treatment administrators.

GENERAL OBSERVATIONS
Persons working in the substance abuse treatment field often make the general
assertion that “treatment works.” In 2003, the Minnesota Department of Human
Services (DHS) summarized previous research by stating in a report to the

SUBSTANCE ABUSE TREATMENT
Legislature that “treatment is effective.”1 According to DHS, “Studies have
consistently found that treatment reduces substance use frequency by at least 40
to 60 percent, and markedly reduces the criminal activity associated with
addictions.”2 But, in our view,
•

There are many
types of substance
abuse treatment,
implemented in
different settings
with various
degrees of skill.

Broad claims—positive or negative—about the effectiveness of
substance abuse treatment are misleading, given variation in past
research findings and a need for more definitive evidence about the
circumstances in which treatment is effective.

First, the term “treatment” is too ill-defined for such generalizations. There are
dozens of treatment approaches, of various lengths and intensities, provided to
persons with different needs, and implemented in many different settings with
various degrees of skill. Some studies provide limited descriptions of treatment
programs’ features and the characteristics of the clients served, making it difficult
to draw general conclusions about what worked with whom. As one summary of
treatment research concluded,
[R]esearch to date has conclusively established that treatment can be
effective, but there are only preliminary indications at this time as to why
treatment is effective or what it is within treatment that makes it
effective.3
Second, previous research on the effectiveness of substance abuse treatment has
produced a mix of positive and negative findings, so a generalization that
“treatment works” is one-sided. One recent research summary said that the
outcomes for some of the more common types of substance abuse treatment “are
rather consistently negative,” but it also said that positive findings for certain
other types of treatment provide “reason for optimism.”4
Third, even when the evidence suggests that, on average, treatment has a positive
impact on a particular population, there will always be individual cases in which
treatment does not lead to favorable outcomes. The assertion that “treatment
works” may imply that treatment always works for all participants, which is
unrealistic. As a recent commentary in a substance abuse journal stated:

Minnesota Department of Human Services, Minnesota’s Chemical Health System: A Report to
the Minnesota Legislature (St. Paul, February 21, 2003), i.

Ibid, 12. The department’s comment is similar to one in National Institute on Drug Abuse,
Principles of Drug Addiction Treatment: A Research-Based Guide (Washington, D.C., October
1999): “According to several studies, drug treatment reduces drug use by 40 to 60 percent and
significantly decreases criminal activity during and after treatment” (p. 13).
3

A. Thomas McLellan and James R. McKay, “Components of Successful Treatment Programs:
Lessons from the Research Literature,” in Principles of Addiction Medicine, 2nd ed., ed. Allan W.
Graham and Terry K. Schultz (Chevy Chase, MD: American Society of Addiction Medicine,
1998), 338.
4

William R. Miller, Paula L. Wilbourne, and Jennifer E. Hettema, “What Works? A Summary of
Alcohol Treatment Outcome Research,” in Handbook of Alcoholism Treatment Approaches:
Effective Alternatives, 3rd ed., ed. Reid K. Hester and William R. Miller (Boston: Allyn and Bacon,
2003), 34, 40.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

The effusive optimism of the [treatment field’s] “Treatment Works”
slogan masks a brutal reality: there are legions of families whose loved
ones are dying addiction-related deaths, languishing in prisons, or living
addiction-deformed lives—all after one or more episodes of addiction
treatment. The slogan “Treatment Works” is painfully contradicted by
the experiences of these families.5

Many studies
have not isolated
the impact of
treatment, apart
from other factors
that can affect
client recovery.

Fourth, the methods used in many studies have not allowed researchers to
determine which client improvements were attributable to treatment rather than
to other factors. Numerous studies have documented reductions in substance use
and criminal behavior by persons during and after treatment, compared with the
period before entering treatment. But people often enter treatment following a
crisis or prolonged problems, so a reduction in substance use or criminal
behavior could be part of a natural course of events, even without treatment. The
most definitive studies of treatment’s impacts are those in which researchers
randomly assign persons either to treatment or no program at all, thus allowing
the researchers to focus on the impact of the treatment experience.
Unfortunately, most studies of substance abuse programs have not compared
outcomes for “treated” clients to “untreated” clients, reflecting the
understandable reluctance of program administrators and researchers to deny
potentially beneficial treatment to persons.6
While it would be misleading to make a sweeping claim that “treatment works,”
it would also be wrong to generalize that “treatment does not work.” As
discussed in the next sections,
•

Studies have demonstrated the potential for certain treatment
programs to reduce clients’ chemical use and improve their social
functioning, based on comparisons to (1) clients who did not receive
treatment, or (2) clients who were in other programs.

In the following sections, we discuss key findings from previous research,
highlighting types of treatment that appear to have stronger evidence of
effectiveness.

RESEARCH ON COMMUNITY-BASED
TREATMENT
Over the past several decades, researchers have conducted hundreds of studies of
community-based substance abuse treatment, examining various treatment
approaches. This section begins by discussing the mixed research findings
regarding “psychosocial” treatments, which typically involve counseling,

William L. White, “Treatment Works: Is it Time for a New Slogan?” Addiction Professional
(January 2005): 23.

A recent report by the National Research Council observed that “the almost complete lack of notreatment control groups in drug treatment research is striking,” and it recommended greater use of
randomized trials that assign some persons to “no treatment.” See National Research Council,
Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us
(Washington, D.C.: National Academy Press, 2001), 252, 258.

SUBSTANCE ABUSE TREATMENT
therapy, or instruction.7 Later, we provide brief discussions on a series of
specific topics related to community-based treatment that, in our view, may be of
particular interest to legislators.

Overall Effectiveness of Psychosocial
Treatments

Minnesota’s
licensed substance
abuse programs
employ
“psychosocial”
treatment
approaches.

In Minnesota, most persons who are assessed by counties as chemically
dependent are referred to “psychosocial” types of treatment. State administrative
rules require licensed substance abuse treatment programs to provide individual
and group counseling, client education strategies, services to help clients make
the transition from treatment to independent daily living, and services to address
co-occurring mental illness.8
In the past 40 years, the federal government has initiated several national studies
of substance abuse treatment outcomes, mostly based on clients who were in
psychosocial treatment.9 These studies looked at data on about 66,000 clients
and provided extensive information on factors associated with positive client
changes following treatment. But the clients in these studies were not randomly
assigned to “comparison groups,” so the National Research Council concluded
that these studies “could not provide rigorous evidence on the relative
effectiveness or efficacy of particular drug-by-treatment combinations, or for
estimating the absolute effect size, cost-effectiveness, or benefit-cost ratio of
treatment.”10
One recent analysis focused on previous studies that included “comparison
groups.” Specifically, it examined 78 studies that compared drug treatment
participants with similar clients who received minimal or no treatment.11 It
concluded that, on average, clients who participated in drug treatment had
somewhat better outcomes than those who received little or no treatment. The
authors reported that treatment had larger impacts on participants’ drug use than

In Chapter 1, we noted that there is no statewide inventory of Minnesota’s substance abuse
programs’ treatment approaches. Thus, it is hard to determine the extent to which Minnesota’s
programs have incorporated the approaches that are most strongly supported by research.
8
Minnesota Rules 2005, 9530.6430. Department of Human Services officials told us that they have
used the state rule-making process to help ensure that treatment is tailored to client needs. As we
discuss in Chapter 3, the department implemented new treatment rules in 2005 and intends to
implement new assessment rules in 2007.
9

The Drug Abuse Reporting Program (DARP) examined 44,000 clients who entered treatment
programs between 1969 and 1973. The Treatment Outcome Prospective Study (TOPS) collected
data on 12,000 clients who entered treatment programs between 1979 and 1981. The Drug Abuse
Treatment Outcome Study (DATOS) reviewed data on 10,000 clients who entered treatment
between 1991 and 1993.

10
11

National Research Council, Informing America’s Policy on Illegal Drugs, 249.

Michael Prendergast, Deborah Podus, Eunice Chang, and Darren Urada, “The Effectiveness of
Drug Abuse Treatment: A Meta-Analysis of Comparison Group Studies,” Drug and Alcohol
Dependence 67 (2002): 53-72. Of the studies reviewed, 59 percent involved “random or quasirandom” assignment of clients to programs. The authors acknowledged that clients’ levels of
motivation could explain some of the results.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

on their levels of criminal activity, concluding that, “overall, people with drug
abuse problems are better off being in treatment than not.”12 However,
•

Studies of
treatment
effectiveness have
produced mixed
results.

Research has not conclusively shown which specific types of
psychosocial substance abuse treatment are more effective than
others.

The question of which types of psychosocial treatment are “best” for particular
clients is a matter of ongoing research. A 2003 review of 381 clinical trials
concluded that several treatment methods have shown evidence of success with
persons having varying levels of alcohol problems.13 Among the psychosocial
approaches, those with the strongest evidence of effectiveness included: (1)
behavior management strategies (for example, teaching clients ways to
exercise self-control, change their thinking patterns, or achieve specific goals);
(2) the “community reinforcement” approach (for example, creating
incentives for clients to reduce their drinking, or working with friends or relatives
on ways to support the clients’ sobriety); (3) strategies to help improve clients’
personal relationships, such as social skills training and certain types of marital
therapy. On the other hand, the authors concluded that many of the more
commonly-used psychosocial treatment approaches—such as psychotherapy,
educational lectures and films, confrontational interventions, and general
substance abuse counseling—had much weaker track records.14
Some direct comparisons of different treatment approaches have not found clear
differences in outcomes. The largest clinical study of substance abuse treatments
(known as Project MATCH) examined the performance of various clients with
three types of outpatient psychosocial treatment: (1) cognitive-behavioral
therapy (helping clients “unlearn” certain habits and cope with situations that
might lead to relapse), (2) 12-step facilitation therapy (based on the “12 steps”
of Alcoholics Anonymous, but involving professionally directed treatment rather
than just self-help groups), and (3) motivational enhancement therapy
(stimulating clients’ self-motivation to make changes, rather than guiding clients
systematically through recovery). The results of Project MATCH indicated that
“the three treatments were not substantially different in their effectiveness.”15
12

Ibid., 66. Even this research summary did not provide definitive evidence of treatment’s
effectiveness. The authors noted that “traditional” types of community-based treatment modalities
were underrepresented in the studies, and that programs rated as being “well implemented” had
better outcomes than other programs (pp. 59, 63).
13

Miller, Wilbourne, and Hettema, “What Works? A Summary of Alcohol Treatment Outcome
Research,” 13-63. The analysis gave greater weight to studies that used stronger research methods.
It identified 18 treatment methods (out of 47 methods with three or more outcome studies) for
which the authors’ ratings of the research evidence was positive, on balance.

Discussing the limitations of their research summary, the authors note that (1) some treatments
have been the subject of much more study than others, and (2) the aggregate ratings of various
treatments do not fully account for the strength of the treatments against which they were compared
in individual studies.
15

William R. Miller and Richard Longabaugh, “Summary and Conclusions,” in Treatment
Matching in Alcoholism, ed. Thomas F. Babor and Frances K. Del Boca (Cambridge: Cambridge
University Press, 2003), 211. When this experiment began in the mid-1990s, cognitive-behavioral
therapy was the only one of these approaches that had clear evidence of its general effectiveness.
The authors noted that the 12-step approach and the closely related Minnesota Model “had not been
subjected to rigorous randomized clinical trials,” and motivational enhancement had strong
evidence for clients with less severe alcohol problems but not for clients with severe problems.

SUBSTANCE ABUSE TREATMENT
The study was designed to determine which treatments worked best with
particular clients, but it found limited evidence of differing effects.16

In practice,
individual
treatment
programs often
use multiple
approaches.

Researchers have often studied the effectiveness of individual treatment
approaches (such as those discussed above), but, in practice, treatment programs
often combine multiple approaches. For example, a program that emphasizes 12
step therapy might also incorporate elements of motivational enhancement
therapy or community reinforcement, for some or all of its clients. Thus, it can
be challenging to categorize a treatment program as having predominantly one
type of approach or another.
The National Institute on Drug Abuse (NIDA)—one of the federal government’s
lead agencies for substance abuse research—has observed that “not all drug
abuse treatment is equally effective.”17 Thus, NIDA developed a set of
“principles of effective treatment” based on reviews of prior research, shown in
Table 2.1. For example, NIDA suggests the need for a variety of treatment
options, due to the fact that no one type of treatment is appropriate for all persons
with substance abuse problems. Also, NIDA suggests that issues other than
substance use—such as mental health, legal, social, and vocational problems—
should be addressed during treatment.

Research Findings on Several Specific Issues
Regarding Community-Based Treatment
The discussion above focused on the overall effectiveness of treatment, including
the effectiveness of various psychosocial treatment approaches. Below, we
briefly summarize research on several other issues. First, psychosocial treatment
is not the only way to treat substance abuse, so we discuss two alternative
approaches that have had particularly strong research findings: methadone
maintenance programs for heroin addicts, and “brief interventions” for problem
drinkers.18 Second, legislators have asked questions about the effectiveness of
treatment for methamphetamine users and adolescents, so we present information
from the limited body of research on these two subpopulations of chemical users.
Third, legislators specifically asked us to address program characteristics that
might influence treatment outcomes. Thus, we discuss previous research on the
16
Ibid., 211-214. The study found that (1) motivational enhancement was more effective for
clients with “high anger” and less effective for clients with “low anger,” (2) 12-step therapy was
more effective than motivational enhancement for clients with social networks that supported their
drinking, (3) 12-step therapy was more effective than cognitive-behavioral therapy for outpatient
clients without psychiatric impairments, and (4) in aftercare settings, cognitive-behavioral therapy
was more effective than 12-step therapy for clients with “low dependence,” while 12-step therapy
was more effective than cognitive-behavioral for clients with “high dependence.” This study was
designed to compare the effectiveness of these three treatments, not to determine whether treatment
resulted in better outcomes than “no treatment.”
17

National Institute on Drug Abuse, Principles of Drug Addiction Treatment, 8.

18
This section discusses methadone maintenance as a treatment for opiate addiction, but some
other medications have been shown to be effective for other addictions. For example, a
comprehensive review of research concluded that two medications (acamprosate and naltrexone)
have been shown to be among the more successful treatments for alcohol-dependent persons. See
Miller, Wilbourne, and Hettema, “What Works? A Summary of Alcohol Treatment Outcome
Research,” 23-26.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

Table 2.1: National Institute on Drug Abuse’s
“Principles of Effective Treatment”

The federal
government has
suggested several
key principles for
substance abuse
treatment.

1. No single treatment is appropriate for all individuals.
2. Treatment needs to be readily available.
3. Effective treatment attends to multiple needs of the individual, not just his or her drug
use.
4. An individual’s treatment and services plan must be assessed continually and
modified as necessary to ensure that the plan meets the person’s changing needs.
5. Remaining in treatment for an adequate period of time is critical for treatment
effectiveness.
6. Counseling and other behavioral therapies are critical components of effective
treatment for addiction.
7. Medications are an important element of treatment for many patients, especially when
combined with counseling and other behavioral therapies.
8. Addicted or drug-abusing individuals with co-existing mental disorders should have
both disorders treated in an integrated way.
9. Medical detoxification is only the first stage of addiction treatment and by itself does
little to change long-term drug use.
10. Treatment does not need to be voluntary to be effective.
11. Possible drug use during treatment must be monitored continuously.
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C,
tuberculosis, and other infectious diseases, and counseling to help patients change
behaviors that place themselves or others at risk of infection.
13. Recovery from drug addiction can be a long-term process and frequently requires
multiple episodes of treatment.
SOURCE: National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A ResearchBased Guide (Washington, D.C., October 1999), 1-3.

length of treatment, whether treatment occurs in an inpatient or outpatient setting,
and the impact of individual counselors. Fourth, there is considerable interest
nationally and in Minnesota in the use of specialized courts for drug offenders,
typically with referral of the offenders to treatment. We discuss research on the
outcomes of these courts. Finally, we discuss self-help groups for chemically
dependent persons, which often supplement professionally-directed treatment (or
are sometimes used in place of treatment).

Methadone Maintenance for Heroin Addiction
Heroin is a highly addictive opiate. In a methadone maintenance program, the
heroin addict takes an oral dose of a legally prescribed drug (methadone) to
reduce or eliminate use of an illegal one (heroin). Methadone is intended to
prevent symptoms of opiate withdrawal and eliminate the intense “highs” and
“lows” associated with heroin use. In Chapter 3, we note that there are only two
programs in Minnesota that have methadone maintenance programs for publiclyfunded clients. Heroin was the primary substance of abuse in about 2 percent of
Minnesota’s 2004 admissions to substance abuse treatment.

SUBSTANCE ABUSE TREATMENT
Extensive research has shown that:
•

Research has
supported the use
of methadone for
heroin addicts.

When properly administered, methadone maintenance therapies for
heroin addicts result in better outcomes, on average, compared with
treatments not involving medications or no treatment at all.

In 1990, the National Academy of Sciences’ Institute of Medicine concluded that
the benefits of methadone maintenance exceeded the cost of treatment. While
acknowledging that some clients “do not respond well to [methadone]
programs,” depending in part on whether the programs set appropriate dosages
for clients, the Institute concluded:
The evidence from experimental and quasi-experimental studies clearly
points toward the existence of a substantial number of heroin-dependent
individuals who perform at least moderately well in response to
methadone maintenance and who would do poorly without it, even when
other kinds of treatment are available.19
According to the federal government’s National Institute on Drug Abuse,
methadone maintenance treatment should last for a minimum of 12 months.20
Studies indicate that some other medications also show promise for heroin
addicts. A recent review of clinical trials found that buprenorphine was an
effective medication for heroin dependence, but not more effective than
methadone administered at appropriate doses.21 Another study found that
buprenorphine, levo-alpha acetylmethadol, and “high-dose” methadone treatment
were all more effective than “low-dose” methadone treatment.22

“Brief Interventions” for Alcohol Abuse
“Brief interventions” for alcohol abuse, as they are usually implemented, are not
considered “treatment” under Minnesota’s substance abuse treatment licensing
rules. Unlike licensed treatment, brief interventions are usually provided by
19

Institute of Medicine, ed. Dean R. Gerstein and Henrick J. Harwood, Treating Drug Problems:
A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment
Systems, v. 1 (Washington, D.C.: National Academy Press, 1990), 136-154. The analysis
concluded that treatment participants had reduced illicit drug use and criminal behavior compared
with (1) untreated persons, (2) persons who were simply detoxified and released, and (3) persons
terminated arbitrarily from methadone. Also, studies have generally shown that higher doses of
methadone are more successful in controlling illicit drug use while clients are in treatment, and
studies have suggested that administration of medication treatments may be enhanced by
counseling.
20

National Institute on Drug Abuse, Principles of Drug Addiction Treatment, 14.

R.P. Mattick, J. Kimber, C. Breen, and M. Davoli, “Buprenorphine Maintenance Versus Placebo
or Methadone Maintenance for Opioid Dependence (Cochrane Review),” in The Cochrane Library,
Issue 1 (2005).
22
Rolley E. Johnson, Mary Ann Chutuape, Eric C. Strain, Sharon L. Walsh, Maxine L. Stitzer, and
George E. Bigelow, “A Comparison of Levomethadyl Acetate, Buprenorphine, and Methadone for
Opioid Dependence,” New England Journal of Medicine 343, no. 18 (2000): 1290-1297. In the
three more effective treatments, the percentage of clients with 12 or more consecutive opium-free
urine tests ranged from 26 to 36 percent, suggesting that complete abstinence is a difficult goal to
achieve.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

“Brief
interventions” by
health care
professionals can
help address
problem drinking
before treatment
is required.

primary care physicians or other health care professionals. Following chemical
use screening, these professionals give clients feedback on their drinking patterns
and provide advice on behavior management techniques. Brief interventions
often have several sessions, each ranging in length from a few minutes to an
hour. They offer little opportunity to teach clients new skills or ways of thinking,
but researchers theorize that these “wake-up calls” enhance some clients’
motivation to change their drinking behaviors.23
One summary of nearly 400 clinical trials of various types of treatments and
interventions concluded that:
•

Among the various types of interventions for alcohol abuse, “brief
interventions” by health care professionals have shown strong
evidence of effectiveness.

Specifically, the authors said that “brief intervention has one of the largest
literature bases and is the most positive by far.”24 Other research summaries
have also concluded that there is strong favorable evidence for brief
interventions.25 Despite such findings, this approach has had limited
implementation in practice across the nation.26 The extent to which Minnesota’s
health care providers use brief interventions is unknown, and staff with the
Minnesota Department of Human Services told us they did not think that the
department has made efforts to promote the use of brief interventions for adults.27

Treatment for Methamphetamine Abuse
In Minnesota, methamphetamine was the primary substance abused in 13.5
percent of admissions to substance abuse treatment in 2004. The growing abuse
of this stimulant has led placement agencies and policy makers to ask which

Paula Wilbourne and William R. Miller, “Treatment for Alcoholism: Older and Wiser?”
Alcoholism Treatment Quarterly 20, no. 3/4 (2002): 44.

Miller, Wilbourne, and Hettema, “What Works? A Summary of Alcoholism Treatment Outcome
Research,” 21. The brief approaches with positive results on balance included brief interventions,
motivational enhancement, case management, and self-administered forms of behavioral selfcontrol training.

For example, see Javier Ballesteros, John C. Duffy, Imanol Querejeta, Julen Arino, and Asuncion
Gonzalez-Pinto, “Efficacy of Brief Interventions for Hazardous Drinkers in Primary Care:
Systematic Review and Meta-Analyses,” Alcoholism: Clinical and Experimental Research 28, no.
4 (April 2004): 608-618, and Robert J. Tait and Gary K. Hulse, “A Systematic Review of the
Effectiveness of Brief Interventions with Substance Using Adolescents by Type of Drug,” Drug
and Alcohol Review 22, no. 3 (September 2003): 337-346.
26

Ann M. Roche and Toby Freeman, “Brief Interventions: Good in Theory But Weak in Practice,”
Drug and Alcohol Review 23 (March 2004): 11-18.

27
For adolescents, DHS has developed the Adolescent Health Review, a screening instrument to
help primary care providers identify behavioral health issues.

SUBSTANCE ABUSE TREATMENT
types of treatment can best address this problem. So far, the amount of rigorous
research on methamphetamine treatment has been very limited.28 In addition,
•

There has been a
limited amount of
rigorous research
on treatment
targeted at
methamphetamine
users and
adolescents.

Research has provided little indication that specialized treatments
for methamphetamine users work better than other treatments.

For example, a large-scale study of methamphetamine users compared the
outcomes of a 16-week outpatient treatment for treating stimulant abuse (the
“Matrix Model”) with outcomes for various types of outpatient “treatment as
usual.” The Matrix Model produced better outcomes during treatment (fewer
failed drug tests and higher program completion rates), but Matrix and the other
approaches had similar post-treatment outcomes on measures of drug use and
client functioning.29 A review of research by University of Iowa researchers
concluded that “special treatment” for methamphetamine abuse was not
supported by previous studies, although longer treatment or client monitoring
might be needed to address the drug’s longer impacts on brain functioning.30
Although research has not identified specialized treatment approaches that are
uniquely effective with methamphetamine addicts, treatments for these clients
may need to be supplemented with other services “to address methamphetamine
patients’ more severe medical and psychiatric problems.”31

Treatment for Adolescents
In Minnesota, about 11 percent of admissions to substance abuse treatment in
2004 were for persons under 18 years old. However,
•

There has been much less research on substance abuse treatment for
adolescents than for adults, and conclusions about “what works” are
still emerging.

One recent research summary identified a total of 15 “controlled evaluations” of
adolescent treatment between 1989 and 2002, compared with more than 300 such

28
Richard A. Rawson, Alice Huber, Paul Brethen, Jean Obert, Vikas Gulati, Steven Shoptaw, and
Walter Ling, “Status of Methamphetamine Users Two to Five Years After Outpatient Treatment,”
Journal of Addictive Diseases 21, no. 1 (2002): 107-119; Yih-Ing Hser, David Huang, Chih-Ping
Chou, Cheryl Teruya, and M. Douglas Anglin, “Longitudinal Patterns of Treatment Utilization and
Outcomes Among Methamphetamine Abusers: A Growth Curve Modeling Approach,” Journal of
Drug Issues (Fall 2003): 921-938.
29

Richard A. Rawson, 14 others, and the Methamphetamine Treatment Project Corporate Authors,
“A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine
Dependence,” Addiction 99 (2004): 708-717.

30
Margaret Cretzmeyer, Mary Vaughan Sarrazin, Diane L. Huber, Robert I. Block, and James A.
Hall, “Treatment of Methamphetamine Abuse: Research Findings and Clinical Directions,”
Journal of Substance Abuse Treatment 24 (2003): 267-277. According to Richard A. Rawson, M.
Douglas Anglin, and Walter Ling, “Will the Methamphetamine Problem Go Away?” Journal of
Addictive Diseases 21, no. 1 (2002): 5-19, many of methamphetamine’s brain impacts appear to be
reversible, but this can take 6 to 12 months of abstinence.
31
Amy L. Copeland and James L. Sorenson, “Differences Between Methamphetamine Users and
Cocaine Users in Treatment,” Drug and Alcohol Dependence 62 (2001): 94.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

evaluations of alcohol abuse treatment for adults.32 As with studies of adult
treatment, most studies have compared one type of adolescent treatment to
another, rather than to comparison groups that received no treatment.33
A 2004 summary of adolescent treatment studies concluded that two types of
psychosocial treatment for adolescents had the strongest support in past research:
(1) “multidimensional family therapy” (individual and family counseling
sessions that address interpersonal relationships), and (2) cognitive-behavioral
treatment groups (helping clients to “unlearn” certain ways of thinking and
improving their ability to cope with difficult situations). It also noted that:
“Although there exists a range of effective and promising treatments, many
interventions were found to be either ineffective or of uncertain efficacy.”34
Two earlier reviews of adolescent treatment research (in 2000 and 2001) were
inconclusive about the relative effectiveness of different types of treatment, due
to the limited number of studies that had been conducted at the time of the
reviews.35 Other researchers have noted that adolescents have usually shown less
favorable outcomes than adults in large-scale treatment evaluations.36

Treatment Duration and Retention
Earlier, we noted that there has been strong research evidence favoring the use of
“brief interventions” among persons with alcohol problems. These interventions
often involve no extended counseling and are often intended to address problems
before there is a need for more intensive services. But, for persons who enroll in
counseling-based programs, researchers have observed that:
•

On average, persons who complete substance abuse treatment
programs or remain in the programs for longer periods are more
likely to experience positive outcomes than persons with shorter or
uncompleted treatments.

32
Michael G. Vaughn and Matthew O. Howard, “Adolescent Substance Abuse Treatment: A
Synthesis of Controlled Evaluations,” Research on Social Work Practice 14, no. 5 (2004): 325
335.
33

Robert J. Williams, Samuel Y. Chang, and Addiction Centre Adolescent Research Group, “A
Comprehensive and Comparative Review of Adolescent Substance Abuse Treatment Outcome,”
Clinical Psychology 7, no. 2 (2000): 138-166, reported finding only two studies that used untreated
control groups.

34
Vaughn and Howard, “Adolescent Substance Abuse Treatment,” 329. The review rated 24
treatment approaches. For the “Minnesota Model” 12-step approach, the review said there were
insufficient data to draw conclusions.
35

Deborah Deas and Suzanne E. Thomas, “An Overview of Controlled Studies of Adolescent
Substance Abuse Treatment,” American Journal on Addictions 10, no. 2 (2001): 178-188, said that
family-based therapies “may be effective” but few studies have used validated measures of
substance use outcomes. It also said that more studies were needed before conclusions could be
drawn about cognitive-behavioral therapy. Williams, Chang, and Addiction Centre Adolescent
Research Group, “A Comprehensive and Comparative Review,” said that outcome studies of
adolescent programs tend to be weak. However, it said that family therapy “appears superior to
other forms of outpatient treatment” (p. 159).
36

Yih-Ing Hser, Christine E. Grella, Robert L. Hubbard, Shih-Chao Hsieh, Bennett W. Fletcher,
Barry S. Brown, and M. Douglas Anglin, “An Evaluation of Drug Treatments For Adolescents in
Four U.S. Cities,” Archives of General Psychiatry 58, no. 7 (2001): 689-695.

SUBSTANCE ABUSE TREATMENT
A summary of several national studies said that beneficial effects from treatment
often materialized after 90 days in treatment.37 Based on general patterns in the
research evidence, the National Institute on Drug Abuse suggested minimum
thresholds of 90 days for residential and outpatient treatment and one year for
methadone treatment. This does not mean that all clients require treatment of at
least these durations, but the Institute said that “research has shown
unequivocally that good outcomes are contingent on adequate lengths of
treatment.”38

There is often a
need for sustained
contact with
clients, even if it
includes periods
of low-intensity
treatment or
monitoring.

Of course, there can be important differences in the intensity and nature of
treatment, even within similar durations. For example, over the course of 90
days, a client might receive 28 hours of treatment in an outpatient program that
has weekly, two-hour meetings, compared with more than 80 hours of treatment
in a 90-day outpatient program that has two-hour meetings three times a week.
The emerging consensus in the substance abuse treatment field seems to be that
there is often a need for sustained periods of contact with clients, even if it
includes periods of low-intensity treatment or monitoring. Two leading
researchers summarize previous research in the following way:
[R]eviews of treatment intensity, length of stay, and aftercare suggest
that an effective strategy may be to provide lower intensity addiction
treatment for a longer duration—that is, treatment spread out at a lower
rate over a longer period…. More extended treatment may improve
patient outcomes because it provides patients with ongoing support and
the potential to discuss and resolve problems prior to the occurrence of a
full-blown relapse.39
In addition, research has shown that it is reasonable to expect better outcomes
among clients who complete the treatment programs they begin. In 2000, the
Minnesota Department of Human Services found that this was true in all types of
substance abuse programs. In fact, for both adults and adolescents, program
completion was the most consistent predictor of clients’ abstinence in the sixmonth period after leaving a program.40 This is consistent with findings from
national research literature. For example, a review of adolescent substance abuse

D. Dwayne Simpson, “A Conceptual Framework for Drug Treatment Process and Outcomes,”
Journal of Substance Abuse Treatment 27, no. 2 (2004): 99-121. This summary said that outcomes
improved “in a generally linear fashion as retention increases from 3 months up to 12 to 24 months
or more.” Another study found relationships between treatment duration and outcomes in
methadone maintenance, outpatient, and long-term residential programs, but not in short-term
residential programs—see Zhiwei Zhang, Peter D. Friedmann, and Dean R. Gerstein, “Does
Retention Matter? Treatment Duration and Improvement in Drug Use,” Addiction 98 (2003): 673
684.

National Institute on Drug Abuse, Principles of Drug Addiction Treatment, 14.

John W. Finney and Rudolf H. Moos, “What Works in Treatment: Effect of Setting, Duration
and Amount,” in Principles of Addiction Medicine, 2nd ed., ed Allan W. Graham and Terry K.
Schultz (Chevy Chase, MD: American Society of Addiction Medicine, 1998): 349.
40

Minnesota Department of Human Services, The Challenges and Benefits of Chemical
Dependency Treatment: Results from Minnesota’s Treatment Outcomes Monitoring System, 1993
1999 (St. Paul, 2000), 3, 32-53.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

treatment found that treatment completion was the variable “with the most
consistent relationship to positive outcome.”41

Inpatient vs. Outpatient Treatment
There are a variety of settings in which chemically dependent persons may be
treated. One key distinction is between “inpatient” treatment, which is provided
in a location where the client resides, and “outpatient” treatment, which is
provided outside the client’s residence. We found that:
•

Either inpatient
or outpatient care
may be
appropriate for
clients, depending
on their
circumstances.

Research has not clearly indicated the superiority of either inpatient
or outpatient care. Either setting may be appropriate for clients,
depending on their circumstances.

One often-cited review of previous research concluded that factors such as
therapist characteristics and the amount of treatment provided had more impact
on clients’ post-treatment functioning than the setting in which treatment
occurred. This review reported that, in 14 studies that specifically examined the
treatment setting, 7 found no differences between inpatient and outpatient
treatment, 5 favored inpatient treatment, and 2 favored outpatient treatment. The
authors suggested using outpatient treatment “for most individuals with sufficient
social resources and no serious medical/psychiatric impairment,” and it also
recommended the development of more intensive outpatient care for certain
clients.42
A 2000 study by the Minnesota Department of Human Services said that, based
on rates of post-treatment abstinence, inpatient treatment was superior for (1)
clients with recent “suicidal behavior,” or (2) “severe” problems in at least four
of the following areas: alcohol use, drug use, psychological distress, social
isolation, and unemployment. But, overall, the study concluded that there were
too few persons placed in outpatient care in Minnesota. It said that 60 percent of
adults treated in inpatient care in Minnesota “would do just as well in outpatient
settings,” while 84 percent of adults in outpatient settings were appropriately
placed.43
In cases where the agencies that make client placements perceive no clear
therapeutic advantage for inpatient treatment, outpatient treatment may be the
more cost-effective option. For example, the Department of Human Services
study estimated in 2000 that the average cost of publicly-funded outpatient
treatment was $1,400, compared with $4,200 for short-term inpatient treatment.44

Williams, Chang, and Addiction Centre Adolescent Research Group, “A Comprehensive and
Comparative Review,” 157.

John W. Finney, Annette C. Hahn, and Rudolf H. Moos, “The Effectiveness of Inpatient and
Outpatient Treatment for Alcohol Abuse: The Need to Focus on Mediators and Moderators of
Setting Effects,” Addiction 91, no. 12 (1996): 1773-1796. Generally, this review concluded, the
more “intensive” treatment (whether inpatient or outpatient) had better results.
43

Minnesota Department of Human Services, The Challenges and Benefits of Chemical
Dependency Treatment, 60.
44
Ibid., 17. The report said the median length of outpatient treatment was 6.5 weeks, while the
median length of short-term inpatient treatment was 3 weeks.

SUBSTANCE ABUSE TREATMENT

Impact of Individual Counselors

The content of
treatment
programs
matters, but so
does the skill of
individual
treatment staff.

The effectiveness of substance abuse treatment depends not only on the content
of the treatment program but also on the way services are provided. In one largescale study, outcomes for the three types of treatment tested were significantly
influenced by the therapist to whom clients were assigned.45 However, as a
leading researcher has commented, “it is less clear what distinguishes more
effective from less effective therapists.”46
Some studies indicate that individual therapists’ ability to listen to their clients
and accurately understand the clients’ perspectives may be an important
determinant of treatment effectiveness. Likewise, the therapists’ manner, tone of
voice, and expectations for the client may affect program outcomes.47

Drug Courts
As of late 2005, Minnesota had nine adult drug courts and four juvenile drug
courts.48 A drug court is a specialized type of court that aims to stop drug
offenders’ substance use and related criminal activity. Drug courts rely on active
judicial involvement in individual cases, close monitoring and drug testing by
probation staff, and offender participation in community-based drug treatment.
The courts may dismiss charges or reduce criminal penalties for persons who
comply with drug court requirements, or they may impose sanctions on non
compliant participants. When offender relapse occurs, the courts often respond
with additional sanctions or enhanced treatment, rather than immediate
termination from the drug court.49 So far,
•

National research suggests that drug courts contribute to reductions
in criminal recidivism, but it has not indicated the extent to which
individual components of drug courts—including substance abuse
treatment—affect program results.

Recently, the U.S. Government Accountability Office (GAO) examined the
results of 27 drug court evaluations from across the nation. It found that
participants in drug court programs usually had rearrest and reconviction rates
that were lower than those of comparison groups in the year following program

Miller and Longabaugh, “Summary and Conclusions,” 214.

46
A. Thomas McLellan, “Is Addiction an Illness—Can It Be Treated?” in Strategic Plan for
Interdisciplinary Faculty Development: Arming the Nation’s Health Professional Workforce for a
New Approach to Substance Use Disorders, ed. Mary R. Haack and Hoover Adger, Jr. (Providence,
RI: Association for Medical Education and Research in Substance Abuse, September 2002), 84.
47

Miller and others, “What Works? A Summary of Alcohol Treatment Outcome Research,” 38-39.

The first drug court started in Miami in 1989, and there were 1,621 drug courts nationwide in
2004, according to C. West Huddleston, III, Karen Freeman-Wilson, Douglas B. Marlowe, and
Aaron Roussell, Painting the Current Picture: A National Report Card on Drug Courts and Other
Problem Solving Court Programs in the United States (Washington, D.C.: Bureau of Justice
Assistance, May 2005), 1.
49

U.S. Government Accountability Office, Adult Drug Courts: Evidence Indicates Recidivism
Reductions and Mixed Results for Other Outcomes (Washington, D.C, February 2005), 38-39.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

completion. Meanwhile, GAO found “mixed results” regarding the substance
use of drug court participants who had completed treatment.50

The role of
treatment in the
success of drug
courts is unclear.

But, in cases where drug courts have shown positive effects, it is unclear whether
they are due to the amount or type of treatment received, the actions of the judge,
the supervision provided by correctional staff, or other factors.51 Researchers
who have observed that drug courts “outperform virtually all other strategies that
have been attempted for drug-involved offenders” have also said that drug courts
are best thought of as “experimental” until more is learned about how they work
and the circumstances in which they are most likely to succeed.52

Self-Help Groups
Finally, it is worthwhile to consider previous research on “self-help” or “mutual
aid” groups, such as Alcoholics Anonymous (AA). These groups do not involve
professionally-directed “treatment,” but they are popular and are often used in
combination with psychosocial treatment. A recent summary of the effectiveness
of these groups concluded the following:
The data about the effectiveness of self-help groups are limited and
mixed. No controlled evaluations of self-help groups other than AA
have been reported, and controlled trials of AA alone have not yielded
positive findings. However, evaluation studies provide suggestive hints
of the positive benefits of AA—large numbers of persons attend and
those who maintain their involvement are likely to abstain from the use
of alcohol. Evidence suggests strongly that combining AA and
professional treatment may enhance the probability of a positive
treatment outcome.53

RESEARCH ON PRISON-BASED
TREATMENT
The community-based programs discussed in the previous sections serve a
variety of clients, including many criminal offenders directed to treatment by the
courts or their probation officers. However, some chemically dependent
offenders are sentenced to prison, due to the severity of their offenses or the
length of their criminal histories. Thus, in addition to reviewing past studies of

50
Ibid., 5-6, 44-61. The studies with statistically significant differences in rearrest rates had
differences ranging from 8 to 35 percentage points. The studies with statistically significant
differences in reconviction rates had differences ranging from 8 to 21 percentage points.
51
Ibid., 5-6; Douglas B. Marlowe, David S. DeMatteo, and David S. Festinger, “A Sober
Assessment of Drug Courts,” Federal Sentencing Reporter 16, no. 2 (December 2003): 156.
52

Marlowe and others, “A Sober Assessment of Drug Courts,” 153, 156. The authors said: “The
not-so-simple fact is that drug courts are neither successful nor unsuccessful. They “work” for
some clients under some circumstances but are ineffective or contraindicated for others. They can
be administered poorly and inefficiently and, unfortunately, we do not know enough to identify
specific errors in implementation” (p. 156).

Barbara S. McCrady, A. Thomas Horvath, and Sadi Irvine Delaney, “Self-Help Groups,” in
Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 184.

SUBSTANCE ABUSE TREATMENT
community-based substance abuse treatment, we also examined research on
treatment provided to prisoners. Many studies have examined the extent to
which persons released from prison commit new offenses, but relatively few have
rigorously examined the role that treatment plays in offender behaviors after
prison. It is challenging for researchers to isolate the impact of treatment
programs from other variables, such as offenders’ willingness to change their
behaviors. In recent years, however, several studies have used careful research
methods to examine the effects of substance abuse treatment in federal and state
prisons.
In general, the more rigorous studies of substance abuse programs have shown
that:
•

Several studies have
shown favorable
outcomes for
prison-based
treatment
programs, at least
in the short term.

On average, prisoners who have participated in treatment have had
more favorable outcomes than prisoners who did not.

In prison-based settings, the strongest evidence of favorable outcomes is from
several studies of “therapeutic communities,” in which the program participants
live together in units separate from the general prison population.54 For example,
one study found that federal prison inmates who completed drug treatment
programs in therapeutic communities were 44 percent less likely to use drugs in
the six months following release than untreated inmates. Also, treated inmates
were 73 percent less likely to be rearrested in the six months following release
than untreated inmates.55
Studies of a California therapeutic community program showed that inmates who
participated in prison-based treatment were significantly less likely to return to
prison than untreated inmates during the first two years following prison release.
Differences between treated and untreated offenders were no longer apparent
three years after release from prison.56
Multi-year studies of prison treatment in Delaware have consistently shown
better outcomes for treated inmates than for comparable groups of untreated
ones. Inmates who completed treatment in prison and participated in post-prison
aftercare had lower levels of drug use and arrests than (1) inmates who
completed prison treatment but did not enter aftercare following prison, (2)

Ojmarrh Mitchell, Doris Layton MacKenzie, and David B. Wilson, “The Effectiveness of
Incarceration-Based Drug Treatment on Offending and Drug Use: An Empirical Synthesis of the
Research,” Paper presented at Annual Meeting of the American Society of Criminology, Chicago,
2002, said that therapeutic communities have been the most effective type of prison-based
treatment.
55
Bernadette Pelissier, Susan Wallace, Joyce Ann O’Neill, Gerald G. Gaes, Scott Camp, William
Rhodes, and William Saylor, “Federal Prison Residential Drug Treatment Reduces Substance Use
and Arrests After Release,” American Journal of Drug and Alcohol Abuse 27, no. 2 (2001): 315
337. This study did not involve random assignment of inmates to treatment, but it used methods
that controlled for the characteristics of inmates entering (or not entering) treatment.
56

Michael L. Prendergast, Elizabeth A. Hall, Harry K. Wexler, Gerald Melnick, and Yan Cao,
“Amity Prison-Based Therapeutic Community: Five-Year Outcomes,” The Prison Journal 84, no.
1 (March 2004): 36-60. Treated offenders had significantly lower return-to-prison rates after five
years, but the study said that this may have been explained by variables other than in-prison
treatment.

PREVIOUS RESEARCH ON TREATMENT EFFECTIVENESS

inmates who dropped out of prison treatment, and (3) inmates who received no
treatment in prison.57

Aftercare may
enhance the effects
of prison-based
treatment, although
further research is
needed.

Likewise, researchers found that Texas offenders who completed both prisonbased treatment and community-based aftercare were less likely to return to
prison than comparable offenders who did not. Positive treatment outcomes in
the three years following release from prison were especially strong for offenders
assessed as having more severe crime and drug-related problems than other
offenders.58
Each of the studies discussed above reported that inmate participation in
community-based aftercare programs (following prison-based treatment) is
associated with improved outcomes. While some researchers have concluded
that in-prison treatment without community-based aftercare has little impact,59
others think that additional research is needed to determine whether the apparent
impacts of aftercare programs are due to enrollment of the more motivated
offenders in these programs.60

James A. Inciardi, Steven S. Martin, and Clifford A. Butzin, “Five-Year Outcomes of
Therapeutic Community Treatment of Drug-Involved Offenders After Release from Prison,” Crime
and Delinquency 50, no. 1 (January 2004): 88-107. Even among inmates who completed
Delaware’s prison-based treatment and community-based aftercare, 52 percent were rearrested and
71 percent used chemicals in the five years after release from prison. The authors tried to control
for differences in the treated and untreated inmates, but they acknowledged that they may have
been unable to account for some variables.
58
Kevin Knight, D. Dwayne Simpson, and Matthew L. Hiller, “Three-Year Reincarceration
Outcomes for In-Prison Therapeutic Community Treatment in Texas,” The Prison Journal 79, no. 3
(September 1999): 337-351. Offenders were not randomly assigned to treatment, but the
researchers considered differences in offender demographics and motivation during the analysis.
59
Clifford A. Butzin, Steven S. Martin, and James A. Inciardi, “Evaluating Component Effects of a
Prison-Based Treatment Continuum,” Journal of Substance Abuse Treatment 22 (2002): 63-69,
noted that the California and Delaware studies found little difference in outcomes for offenders
who only received treatment in prison and those who received no treatment.
60

Prendergast and others, “Amity Prison-Based Therapeutic Community,” 55.

Community-Based
Treatment: Use and
Availability
SUMMARY

There is uneven access to publicly-funded substance abuse treatment
across the state, despite the existence of uniform placement criteria. Local
assessment and referral practices vary, and they have been subject to
insufficient oversight by the Minnesota Department of Human Services.
Treatment availability also varies, and the department should foster the
development of appropriate amounts and types of treatment to effectively
meet clients’ service needs. Local officials have particular concerns about
the lack of adequate treatment options for adolescents, persons with dual
diagnoses of substance abuse and mental illness, and methamphetamine
users.

tate law establishes a policy advocating rehabilitative services for persons
with substance abuse problems. But treatment cannot have positive effects if
the people who need it do not have access to it. This chapter addresses the
following questions:
•

To what extent do Minnesota counties vary in how they assess and
refer clients to community-based chemical dependency treatment?
Should policy makers be concerned about these variations?

•

Do local human services agencies have consistent, appropriate
methods for assessing the needs of individuals for community-based
substance abuse treatment? Has the Department of Human Services
adequately overseen local assessment and referral practices?

•

How has state policy affected eligibility for and use of publiclyfunded substance abuse treatment? To what extent do counties vary
in their financial responsibility for the costs of publicly-funded
treatment?

•

Is there adequate community-based treatment to meet the needs of
local agencies in Minnesota? Has the Department of Human
Services taken sufficient steps to ensure the availability of
appropriate treatment throughout Minnesota?

SUBSTANCE ABUSE TREATMENT

DEPARTMENT OF HUMAN SERVICES’
ROLE
State law assigns the Minnesota Department of Human Services (DHS) important
regulatory and oversight responsibilities that affect Minnesotans’ access to
publicly-funded treatment. First, the law requires DHS to establish statewide
criteria to determine which persons shall be placed in various types of publiclyfunded treatment.1 Second, since 1984, state law has required DHS to monitor
“the conduct of [substance abuse] diagnosis and referral services,” which are
performed by counties and tribal agencies.2 Third, the law assigns DHS lead
responsibility among state agencies for helping to ensure that Minnesota has a
coherent, coordinated system of treatment. For example, the department must
prepare a statewide plan for chemical dependency services, and it is supposed to
develop new approaches for addressing chemical dependency problems.3
Consistent with these responsibilities, DHS has adopted statewide placement
criteria, which we discuss later in this chapter. In addition, DHS is in the process
of developing new assessment rules that are intended to promote more
individualized services. DHS has also provided statewide training on various
substance abuse prevention and treatment services. While these efforts have
been important and valuable,
•

Stronger DHS
leadership,
oversight, and
guidance could
help address
inconsistencies in
substance abuse
treatment.

The Department of Human Services has not (1) provided enough
oversight of county practices for placing clients in treatment, or (2)
fostered the development of sufficient amounts and types of
treatment to effectively meet clients’ service needs.

As we discuss in this chapter, Minnesota has not yet achieved equitable access to
publicly-funded treatment. Some clients appear to have better access to services
than others, depending on where they live and their service needs. This problem
results partly from local variation in (1) assessment and referral practices, and (2)
the availability of appropriate treatment services. Local agencies determine who
should be treated, where they should be treated, and how state treatment funds
should be spent. However, DHS does not systematically examine local agencies’
compliance with state regulations on client assessment and referral, nor has the
department identified model instruments for assessing clients.4 And, despite
some efforts by the department to foster new treatment programs and approaches,
important gaps in services remain around the state.
We recognize that it is not possible to have entirely uniform access to treatment
throughout the state. There will always be some geographic regions or types of
1

Minnesota Statutes 2004, 254A.03, subd. 3, and 254B.03, subd. 1.

Minnesota Statutes 2004, 254A.03, subd. 1.

Ibid.

Prior to 2003, state law required the department to conduct “quality control audits” of county
social services, but DHS officials told us that the agency has not conducted these reviews of local
chemical health services since before 2000. In late 2005, DHS assigned chemical health staff to
various regions of the state to improve its communications with local officials on treatment-related
issues.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

clients that are more difficult to serve than others. Also, some differences in the
use of treatment reflect differences in counties’ spending preferences or their
residents’ service needs. But, in our view, important inconsistencies could be
addressed with stronger DHS leadership, oversight, and guidance. We offer
specific recommendations later in the chapter.

COUNTIES’ USE OF SUBSTANCE ABUSE
TREATMENT

Publicly-funded
treatment is
targeted toward
people with low
incomes.

In 2003, the Department of Human Services reported “considerable variation” in
counties’ admission rates to treatment, including both publicly- and privatelyfunded treatment.5 For our report, we focused on the use of publicly-funded
treatment, which is targeted in Minnesota toward persons with household
incomes at or below the poverty level. To help us account for variations among
counties in their levels of poverty, we compared each county’s number of adults
using publicly-funded treatment to the county’s number of adults in poverty.6 As
shown in Table 3.1, we used two measures of treatment utilization, obtained from
independent sources.7 From our analysis, we concluded that:
•

Counties’ widely varying rates of treatment use suggest that there is
uneven access to publicly-funded substance abuse treatment around
the state.

Statewide, during 2003 and 2004, there were 80 admissions of adults to publiclyfunded treatment per 1,000 adults living in poverty. The rates for individual
counties ranged considerably, from 168 in Mahnomen County to 22 in Kittson
County. Thus, low income persons from Mahnomen County were about eight
times more likely to be admitted to publicly-funded treatment than low income
persons from Kittson County. In the seven-county Twin Cities area, the number
of adult admissions to publicly-funded treatment per 1,000 adults living in
poverty ranged from 129 in Anoka County to 53 in Dakota County. Analyses
based on local agencies’ client authorizations for publicly-funded treatment
showed similar patterns (see Table 3.1). Some variation in the use of publiclyfunded treatment may reflect differences in the incidence of substance abuse

Minnesota Department of Human Services, Minnesota’s Chemical Health System: A Report to
the Minnesota Legislature (St. Paul, February 2003), 6.

Estimates of individual counties’ poverty-level populations are not very accurate in the years
between the decennial census. For our analysis, we used each county’s 1999 poverty-level
population, as reported in the 2000 U.S. Census.

First, we determined the number of clients authorized for treatment paid for by the Consolidated
Chemical Dependency Treatment Fund (CCDTF), according to the clients’ county of residence.
This information is reported by counties and tribes to DHS. Second, we determined the number of
admissions to treatment funded by either the CCDTF or the Prepaid Medical Assistance Program,
as reported by treatment providers to DHS.

SUBSTANCE ABUSE TREATMENT
among subgroups of low income persons, but the extent of such differences is
unclear.8

Table 3.1: Utilization of Publicly-Funded Treatment,
2003-04
Average Number of Adult
Residents Authorized for
Treatment Annually per
1,000 Adults in Poverty

Average Number of Adult
Admissions into PubliclyFunded Treatment per
1,000 Adults in Poverty

Statewide

Twin Cities Metro Area
Washington
Hennepin
Anoka
Scott
Carver
Ramsey
Dakota

81
109
95
78
72
70
65
56

92
118
109
129
100
92
55
53

Outstate Counties

Select Outstate Counties With
Highest Rates
Mahnomen
Beltrami
Becker

155
136
102

168
156
120

Select Outstate Counties With
Lowest Rates
Stevens
Winona
Lincoln
Kittson

17
16
14
12

34
24
28
22

Region/County

NOTE: We calculated the average number of annual treatment authorizations and admissions by
using data for a two-year period (2003-2004). Treatment authorization rates are based on approved
client placement authorizations reported from both counties and tribes to the Department of Human
Services, by clients’ county of residence. We calculated admissions into treatment using data on
treatment services reported by treatment providers to the department. Some counties’ low admission
rate relative to their treatment authorization rate may be partly due to underreporting by providers to
the department or clients’ failure to appear for treatment. The number of admissions is typically
higher than the number of authorizations because (1) the admissions data include treatment funded
by either the Consolidated Chemical Dependency Treatment Fund (CCDTF) or the Prepaid Medical
Assistance program, while the authorizations data include only CCDTF-funded cases, and (2) clients
may be admitted to more than one treatment program following a county assessment, such as
inpatient care followed by outpatient care.
SOURCE: Office of the Legislative Auditor’s analysis of data from the Department of Human
Services and 2000 U.S. Census.

Demographic factors such as racial or cultural differences may contribute to some of the
differences in counties’ overall rates of treatment utilization. For example, the three outstate
counties shown in Table 3.1 with high treatment utilization (Mahnomen, Becker, and Beltrami)
each have sizable American Indian populations and, in each of these counties, American Indians
accounted for a larger share of 2003-04 publicly-funded adult chemical dependency treatment
admissions than their share of the adults in poverty. However, within individual racial categories,
we also found sizable differences among counties’ rates of treatment utilization by low income
persons.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Wide variation in
referrals to
publicly-funded
treatment
suggests uneven
access to services.

We also found that the use of publicly-funded treatment for adolescents varied
widely around Minnesota, suggesting uneven access to services. Among the
counties with at least 200 adolescents in poverty-level households, five had fewer
than 20 treatment admissions in 2003-04 per 1,000 adolescents in poverty-level
households, while six counties had more than 100 admissions per 1,000
adolescents in poverty-level households. Among individual counties, the number
of admissions per 1,000 adolescents in poverty ranged from 183 in Cass County
to 10 in Fillmore County.9
We also looked at counties’ use of various types of care for clients. As we noted
earlier, Minnesota law requires the Commissioner of Human Services to establish
uniform statewide placement criteria that counties and tribes must use to
determine the appropriate “level of care” for public assistance recipients who
seek chemical dependency treatment.10 However,
•

The type of care that individuals receive depends considerably on
which county makes the placement.

Currently, state assessment rules identify the following “levels of care”:
outpatient, primary rehabilitation (sometimes called “inpatient care”), extended
care, and halfway houses (see Table 1.4). Each type of care has state-specified
placement criteria. Statewide, counties rely mostly on outpatient services for
clients who are authorized for treatment paid for by the Consolidated Chemical
Dependency Treatment Fund, as shown in Table 3.2. During the 2003-04 period,
61 percent of these publicly-funded clients were referred to outpatient care at
least once (in combination with or exclusive of other care). Meanwhile, 31
percent of clients had a referral to inpatient treatment, 25 percent had a referral to
a halfway house, and 12 percent had a referral to extended care.
But Table 3.2 shows that individual counties differed considerably in their use of
the various levels of care for clients authorized for publicly-funded treatment.
For example, Dakota used outpatient care for 83 percent of its clients, while
another Twin Cities county (Anoka) used outpatient care for just 52 percent of its
clients. Some counties used inpatient care for less than 20 percent of their
publicly-funded clients, while LeSueur County placed 63 percent of its clients in
inpatient care. Overall, counties in the Twin Cities area tended to rely more on

The rates cited here are from the 40 counties that had at least 200 persons ages 12 to 17 living in
poverty-level households, according to 2000 census data. We examined the number of adolescents
admitted to publicly-funded treatment in 2003 and 2004 and compared the average annual number
of admissions of residents from each county to the county’s total number of adolescents who,
according to census data, lived in households with poverty-level incomes. An analysis of counties’
treatment authorizations during this period showed similarly wide variation to what we found in the
admissions data.
10

Minnesota Statutes 2004, 254A.03, subd. 3. According to the law, “the criteria shall address, at
least, the family relationship, past treatment history, medical or physical problems, arrest record,
and employment situation.”

SUBSTANCE ABUSE TREATMENT

Table 3.2: Select Counties’ Treatment Referral Practices for

Consolidated Chemical Dependency Fund Clients, 2003-04

Average
Number of
Care Levels
per Client

Region/County

Percentage
of Clients
With at
Least One
Inpatient
Referral

Percentage
of Clients
With at
Least One
Outpatient
Referral

Percentage
of Clients
With at Least
One
Extended
Care Referral

Percentage
of Clients
With at Least
One Halfway
House
Referral

Median Age
of Clients
Assesseda

Statewide

1.3

30.7%

61.4%

12.5%

24.6%

Twin Cities Metro Area
Scott
Anoka
Hennepin
Washington
Ramsey
Carver
Dakota

1.3
1.4
1.4
1.3
1.3
1.1
1.1
1.1

25.2
34.2
39.0
26.5
23.1
18.6
18.3
14.8

68.7
62.1
52.4
64.4
73.4
79.6
65.2
82.9

11.9
14.0
14.3
13.0
9.9
9.6
12.1
3.0

23.9
33.9
35.5
30.7
24.8
3.2
14.7
8.3

34
28
30
36
29
35
27
29

Outstate

1.4

40.2

54.1

14.0

27.1

1.6
1.5
1.5
1.1
1.1

45.2
43.0
43.1
18.9
63.0

48.7
57.0
54.9
67.0
33.8

22.6
20.3
11.8
8.5
3.2

41.9
33.9
44.4
13.2
7.1

29
25
29
34
25

Select Counties
Otter Tail
Kandiyohi
Mille Lacs
Pennington
LeSueur

NOTE: Analysis represents only those clients who were assessed and authorized for treatment paid for by the Consolidated Chemical
Dependency Treatment Fund. It includes clients and referrals for each county in which a client was assessed and authorized for CCDTFfunded treatment during 2003-04; assessments and referrals by tribal agencies were excluded. All analysis of care levels and inpatient
referrals includes both primary inpatient care and combination inpatient portions of referrals. Primary outpatient and combination
outpatient portions of referrals are also combined.
a

Based on clients’ age at time of most recent assessment for that county or region.

Counties with more than 100 residents assessed and authorized for CCDTF-funded treatment during 2003-04.

SOURCE: Office of the Legislative Auditor’s analysis of Department of Human Services’ Client Placement Authorization data.

outpatient treatment and less on inpatient care than counties elsewhere in the
state.11
Also, some counties were considerably more likely than others to refer clients to
multiple levels of care during this two-year period. Such referrals might be done
to provide a sequence of treatment to clients (such as inpatient care followed by
outpatient care), or to try different treatment approaches with clients who have
been through treatment previously. Table 3.2 shows that the average client
authorized for publicly-funded treatment from Otter Tail County was referred to
1.6 levels of care during 2003-2004. In contrast, clients authorized for treatment
11

Data on total admissions in the 2003-04 period showed similar variation in county placement
patterns. Among counties with more than 100 admissions into treatment by their residents in 2004,
the percentage of admissions into inpatient care ranged from 11 percent in Carver County to 54
percent in Cass County. Admissions into outpatient care ranged from 17 percent of all admissions
in Otter Tail County to 69 percent in Dakota County.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

from counties such as LeSueur and Dakota were usually referred to just one type
of care.
We offer no opinions about whether individual counties have made the “right”
types of treatment referrals. For example, placing clients in multiple levels of
care is not necessarily preferable to placing them in single levels of care. While
it is reasonable to expect some variation in counties’ referral practices and use of
treatment, the large variations we note here suggest uneven access to treatment
services. Interviews and surveys led us to consider two possible explanations,
discussed in the next sections: (1) differences in local assessment practices, and
(2) differences in the availability of treatment services around the state.

CHEMICAL USE ASSESSMENTS

Counties are
“gatekeepers” for
Minnesota’s
publicly-funded
substance abuse
treatment
services.

County agencies play key roles as “gatekeepers” in Minnesota’s chemical health
system, conducting assessments and making referrals to publicly-funded services.
Given the variation among counties in substance abuse treatment utilization
discussed in the previous section, we explored local variation in the assessment
process. We focused on assessments that are conducted by, or on behalf of,
county human services agencies for the purpose of making referrals to treatment.
These assessments are commonly referred to as “Rule 25” assessments.12

Scope of County Assessment Responsibilities
State law requires that each local human services agency “provide chemical
dependency services to persons residing within its jurisdiction who meet criteria
established by the [Commissioner of Human Services] for placement in a
chemical dependency residential or nonresidential treatment service.”13 To be
placed in publicly-funded treatment, state rules require persons to first undergo a
chemical use assessment.14 These assessments are conducted by counties and
American Indian tribes, as well as prepaid health plans that contract with the
Department of Human Services.15 The assessments determine whether

Minnesota Rules 2005, 9530.6600-6660, are commonly referred to as Department of Human
Services “Rule 25.” We did not examine in detail the chemical use assessments of persons
convicted of impaired driving, which are conducted by court-appointed assessors. According to
Minnesota Statutes 2004, 169A.70, the impaired driving assessments must be conducted by
assessors who meet the training requirements specified in state rules for Rule 25 assessors. Like
Rule 25 assessments, these assessments indicate the severity of the person’s chemical involvement
and recommend a level of care. The law requires assessment reports on convicted impaired drivers
to be submitted to the courts and the Minnesota Department of Public Safety.
13

Minnesota Statutes 2004, 254B.03, subd. 1.

Minnesota Rules 2005, 9530.6615, subp. 1.

Minnesota Rules 2005, 9530.6610, subp. 1 requires counties to assess “all clients who seek
treatment or for whom treatment is sought.” But the rules also require prepaid health plans to
assess and place their enrollees, using the placement criteria in the rules. In addition, DHS
contracts with each tribal government to assess persons living on reservations.

SUBSTANCE ABUSE TREATMENT
individuals have chemical use problems and, if so, the programs to which they
should be referred.16
In addition to assessing persons before they are placed in publicly-funded
treatment, county human services agencies have broader responsibilities for
chemical use assessments and services. Since 1979, counties have received
block grants from the state to help them provide a system of social services,
including services for persons with drug or alcohol problems. The state’s
Community Social Services Act provided the statutory framework for this system
until its repeal in 2003.17 Since then, the Children and Community Services Act
has governed the state and local system of social services.18 However,
•

Recent changes in
state laws gave
counties more
latitude to
determine whom
to assess.

State law does not explicitly define which persons local human
services agencies must assess for chemical dependency, and this
contributes to variations in clients’ access to services.

Until 2003, state law required counties to conduct “an assessment of the needs of
each person applying for [social services] assistance.”19 Chemical health
officials from the Minnesota Department of Human Services told us that they
instructed counties to assess all persons seeking chemical use assessments,
without regard to eligibility for publicly-funded treatment.20
The 2003 Legislature made significant changes to the laws governing countyadministered social services. The new act gave counties more latitude to curtail
services, including assessment, due to funding limitations. The law no longer
required assessment of each person seeking assistance, and assessment was not
among the services that were required to receive counties’ “highest funding
priority.”21 Department of Human Services officials said they did not know
whether legislators were fully aware that the 2003 statutory changes weakened
the assessment obligations of county human services agencies.
We visited eight counties and conducted phone interviews with chemical health
staff in several other counties. We found that local human services agencies vary
in their policies regarding which clients they will assess. For example, most
county human services agencies we contacted said they would assess any person

State rules also require licensed treatment programs to conduct a “comprehensive assessment” of
clients within three calendar days of service initiation, examining all of the areas listed in Table 3.3.
Thus, Rule 25 assessments are not the only assessments of clients, but they are a critical first step
toward directing clients to services that will address their needs.

Minnesota Statutes 2002, 256E.01-256E.115 (repealed by Laws of Minnesota 2003 First Special
Session, chapter 14, art. 11, sec. 12).
18

Minnesota Statutes 2004, chapter 256M.

Minnesota Statutes 2002, 256E.08, subd. 1.

State chemical dependency rules do not address the obligation of counties to assess persons who
are not eligible for publicly-funded treatment. Minnesota Rules 2005, 9530.6615, subp.1, requires
counties to “provide a chemical use assessment for each client seeking treatment or for whom
treatment is sought,” where “client” is defined as a person who is eligible for treatment funded by
certain public programs.
21

Laws of Minnesota First Special Session 2003, chapter 14, art. 11, sec. 8.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Many counties
assess anyone who
is referred for an
assessment, but
some counties do
not.

who requested or was referred for a chemical use assessment.22 However, two
counties told us that they initially determine a person’s eligibility for publiclyfunded treatment, and they will not assess persons who are not eligible for such
treatment. Persons in these two counties could be assessed by other trained
substance abuse assessors, such as probation staff or private vendors, but they
might have to pay for it.23
Another county’s Rule 25 assessment staff told us they will not conduct chemical
use assessments of persons who do not admit to a substance abuse problem. For
example, in a case where the court orders an assessment but the offender denies a
substance abuse problem, the offender would be expected to pay for an
assessment by a private vendor.24
Thus, while many human services agencies are willing to assess all persons who
seek assessments or are referred for assessments, some are not. As a result, some
persons have to pay for assessments that persons in other counties would receive
free of charge. It is plausible that this discourages some persons from seeking
assessments and, consequently, receiving treatment.25

Assessment Procedures
State administrative rules establish a uniform framework for Rule 25 chemical
use assessments. First, staff who conduct the assessments must meet minimum
education and training requirements.26 Second, the rules set general requirements
regarding the content of assessments. Assessments must include a personal
interview with the client, a “review of relevant records or reports regarding the
client,” and contacts with other persons who are familiar with the client’s
circumstances.27 Rule 25 assessors must consider the topics listed in Table 3.3
22

Counties typically encourage persons to get assessments from their insurers, if they have
insurance, because insurers may have their own criteria for making referrals to treatment.
However, if insured persons prefer to have the county conduct an assessment, most staff in most
counties we visited told us they would do so.
23

In a statewide survey of directors of community-based corrections agencies, 30 percent of the
directors said that their agencies had at least one probation officer who regularly conducted Rule 25
assessments. The survey asked the directors not to consider the assessments of impaired drivers
required by Minnesota Statutes 2004, 169A.70 when responding to this question.
24

Staff in this county told us they do not think they have authority in law or rule to make clinical
judgments about service needs for clients who do not admit to problems. The Minnesota
Department of Human Services disagrees with this interpretation, noting that there are no
exclusions in state rules for persons who are not motivated to change their behaviors.

There are no statewide data on the extent to which persons seek treatment but do not receive it,
either because the assessor did not recommend placement or because no assessment was conducted.
26
Minnesota Rules 2005, 9530.6615, subp. 2. There are several ways to meet the requirements, all
of which require completion of 30 hours of classroom instruction on chemical dependency
assessment in addition to other requirements for education or work experience. Also, assessors
must annually complete at least eight hours of in-service training or continuing education.
27
Minnesota Rules 2005, 9530.6615, subp. 3. The rules require “collateral contacts,” which may
include contacts with family members, criminal justice agencies, educational institutions, and
employers. The rules do not specify how many collateral contacts must be made, and they require
assessors to explain reasons in client records for any failures to make collateral contacts.
Regarding the personal interviews with clients, staff in the eight counties we visited indicated that
the typical length of these interviews ranges from 30 minutes in one county to two hours in another.

State rules
establish a
uniform
framework for
chemical use
assessments.

SUBSTANCE ABUSE TREATMENT
during the assessment process. Third, assessors must rate each client’s “level of
chemical involvement” as: (a) no apparent problem, (b) “at risk” of developing
future problems associated with chemical use, (c) chemical “abuse,” or (d)
chemical “dependence” (a more severe level of substance use than the other
categories). Fourth, state rules specify an appeals process for clients who
disagree with the results of an assessment.

Table 3.3: Required Topics for Consideration in Rule
25 Assessments
• Amount and frequency of chemical use
• Client characteristics (age, sex, cultural background, sexual preference, and

location of home)

• Client’s behaviors under the influence of chemicals
• Family issues (family status and history, level of family support, effects of client’s
chemical use on family members and significant others, and effect on client of
chemical use by family members or significant others)
• Client’s prior assessments or attempts at treatment (for chemical use or mental
illness)
• Client’s physical or mental disorders
• Prior arrests or legal interventions related to chemical use
• Impact of chemicals on client’s ability to work
• Impact of chemicals on client’s ability to learn
SOURCE: Minnesota Rules 2005, 9530.6620, subp. 1.

Local Officials’ Perceptions Regarding Rule 25 Assessments
To help us evaluate the adequacy of Rule 25 assessments, we surveyed the
directors of community-based corrections agencies. These agencies frequently
refer criminal offenders for Rule 25 assessments. As shown in Table 3.4, most
corrections agency directors said that their counties’ Rule 25 assessments are
generally accurate in identifying which offenders need treatment. However,
•

Many corrections directors expressed concerns about the

consistency, timeliness, and thoroughness of the assessments.

For example, 41 percent of the directors said that there is “sometimes,” “rarely,”
or “never” consistency between counties in their application of the state’s criteria
for determining clients’ need for placement. Also, 32 percent of the directors,
including directors serving five of the state’s seven largest counties, said that
offenders’ mental health needs are “sometimes,” “rarely,” or “never” adequately
considered during Rule 25 assessments.
In addition, some county and judicial officials expressed concerns about the
timeliness of Rule 25 assessments. State rules do not specify what constitutes a
reasonable time period for completing a Rule 25 assessment following a client’s
referral, and local agencies do not report data to the Department of Human
Services that could be used to measure how much time elapses.28 In some cases,
28

Lacking a benchmark for timeliness in state rules, we did not ask corrections directors in our
survey to rate the timeliness of the Rule 25 assessment process. Still, several respondents
commented on this issue.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

local officials told us that assessments are done promptly. For example,
defendants arraigned in Hennepin County’s drug court typically receive their
Rule 25 assessments on the same day as their first court appearance. However,
we also heard concerns such as the following:
A corrections director in western Minnesota said: “In some of our
counties, it can be three months or so before we receive the assessment
back. During this time, the offender is not receiving services in the
community and is most likely continuing to use, which increases the
likelihood of probation violations or new offenses.”
A corrections director in northern Minnesota said: “Waiting lists [for
assessment] can be as long as three months on occasion. Very
concerning because this may jeopardize public safety and health of
offender.”

Table 3.4: Local Corrections Directors’ Perceptions
of Rule 25 Assessments
Percentage of Directors Who Said:
Always,
Almost
Always, or
Usually

Sometimes,
Rarely, or
Never

Don’t Know

There is good communication between our
agency and the Rule 25 assessors of the
offenders we supervise.

92%

Rule 25 assessments conducted in my
agency’s county accurately identify which
offenders need treatment.

Probation officers provide assessment staff
with information on the offense history of
offenders referred for assessment.

Within counties with more than one Rule 25
assessor, there is consistency among
assessors in their application of state criteria.

The mental health needs of offenders are
adequately considered during the Rule 25
assessment process.

Rule 25 assessments rely too much on selfreported information from the subjects of the
assessments.

Between counties, there is consistency
among Rule 25 assessors in their application
of state criteria.

SOURCE: Office of the Legislative Auditor’s survey of community-based corrections directors,
September 2005 (N=54). Persons who responded “not applicable” were excluded from the
calculations.

Some local
corrections
officials report
that chemical use
assessments are
not timely or rely
too much on selfreported
information.

SUBSTANCE ABUSE TREATMENT
In various locations around the state, judges and local human services officials
told us about difficulties getting timely assessments for offenders who were in
jail outside their home counties. For example, some described situations in
which the offender’s home county refused to allow the county in which the jail
was located to conduct the assessment, but the home county also refused to send
staff to the jail to conduct the assessment.29
Some corrections directors also expressed concerns about the thoroughness of
Rule 25 assessments. As shown in Table 3.4, 41 percent of the corrections
directors responding to our survey said that the assessments “usually,” “almost
always,” or “always” rely too much on self-reported information from the
offenders. Most corrections directors said that their agencies typically provide
information to the Rule 25 assessors on offenders’ criminal histories, but some
agencies expressed frustration that they are not consulted by the assessors more
regularly:
A corrections official from a county in the Twin Cities metropolitan area
said: “It should be a requirement that, if there is an assigned probation
officer, he/she be contacted as a collateral contact during the assessment
and referral process.”30
A corrections director in northern Minnesota said: “We, many times,
have a ton of information (reports, assessments, investigations) on
clients that we could, if asked and with appropriate signed release,
provide to [the Rule 25] assessor and treatment facility.”

Assessment Instruments
We met with human services staff in eight counties to discuss their assessment
practices in more detail. In each county, we reviewed the instruments that the
Rule 25 assessors used to collect information from the people they assess. Table
3.3 listed topics that must be addressed during these assessments, although state
rules do not prescribe that assessors use a particular assessment instrument. In
our site visits, we found that:
•

Counties use varied approaches to conduct chemical use

assessments, which probably contributes to inconsistencies in

assessors’ conclusions regarding clients’ service needs.

All of the counties we visited use some sort of structured interview to gather
information from clients during the assessment process. Most rely extensively on
instruments they developed rather than commercial instruments. As a result,
there are differences among the instruments, such as those shown in Table 3.5.

Also, officials in several counties told us that there have been occasional disputes about which
county is the “home county” of a person needing an assessment. Financial responsibility for human
services is governed by Minnesota Statutes 2004, chapter 256G (Minnesota Unitary Residence and
Financial Responsibility Act), but counties have sometimes had differing interpretations of this law.
30

The 2005 Legislature passed a law requiring assessors to contact probation officers during
chemical use assessments of persons convicted of impaired driving, but there is no such
requirement for Rule 25 assessments (see Laws of Minnesota 2005, chapter 136, art. 18, sec. 9).

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Table 3.5: Examples of Differences in Counties’
Substance Abuse Assessment Instruments
Withdrawal symptoms: One of the criteria for determining whether someone is
chemically dependent is whether the person has experienced withdrawal symptoms
following cessation of chemical use. Some counties’ instruments had specific questions
that addressed this. For example, one county listed 16 symptoms with the following
question: “Have you ever felt any of the following after two days or longer of not
using/drinking?” In contrast, some instruments simply asked clients whether they had
experienced withdrawal (with no discussion of possible symptoms), and other instruments
had no questions that specifically addressed withdrawal.

There are
important
differences in
counties’
practices for
conducting
chemical use
assessments.

Mental health symptoms: Some counties’ instruments had a series of specific questions
in which assessors asked clients about current or previous mental health problems—for
example, prior diagnoses, hospitalizations, medications, or other treatments for mental
illness; thoughts of suicide or suicide attempts; histories of emotional, sexual, or physical
abuse, eating disorders, or violent behaviors; and use of chemicals to cope with
depression. In contrast, some counties’ assessment instruments only had open-ended
categories (such as “mental health history”) with no specific questions, leaving
considerable discretion to the assessors.
SOURCE: Office of the Legislative Auditor’s review of assessment instruments in select counties.

There are also potential inconsistencies within counties. One county uses several
instruments that differ considerably in detail and format, and each of its assessors
uses the instrument he or she prefers. In another county, judges told us that some
Rule 25 assessors are more likely to recommend treatment than others, and that
judges sometimes consider this when deciding where to refer offenders for
assessment.
We also examined whether individual counties have implemented specialized
approaches to assess adolescents. Adolescents and adults often have similarities
in their patterns and symptoms of substance use. But, as one recent research
review concluded, “it appears just as likely that an adolescent could be using
substances problematically, yet bear little or no resemblance to an adult with a
substance-use disorder. In this respect, the need for adolescent-specific
assessment is apparent.”31 Also, a young adolescent who drinks alcohol regularly
might warrant some sort of intervention, even if the same consumption level in
an adult would not necessarily be cause for concern.32 The American Society for

31
William R. Miller, Verner S. Westerberg, and Holly B. Waldron, “Evaluating Alcohol Problems
in Adults and Adolescents,” in Handbook of Alcoholism Treatment Approaches: Effective
Alternatives, 3rd ed., ed. Reid K. Hester and William R. Miller (Boston: Allyn and Bacon, 2003),
83.
32

Ibid.

SUBSTANCE ABUSE TREATMENT
Addiction Medicine has recommended the use of distinct placement criteria for
adults and adolescents, although Minnesota rules do not specify separate
criteria.33 We found that:
•

For the most part, Rule 25 assessors in the counties we visited do not
use adolescent-specific assessment instruments or placement criteria.

Most of these counties conduct structured interviews of adolescents using
instruments that are similar to (or the same as) those used for adults.34 There are
a variety of commercial instruments specifically designed for assessing
adolescent substance use, although the “state of the art” in adolescent assessment
is less developed than adult assessment.35

County Findings of “Abuse” and “Dependence”

Determinations of
“abuse” and
“dependency”
affect the types of
treatment clients
are eligible to
receive.

The types of care in which publicly-funded clients can be placed depend partly
on whether the clients are determined by assessors to be chemically “dependent,”
rather than chemically “abusive.” For example, according to Minnesota’s
administrative rules, clients cannot be placed in inpatient treatment or extended
care unless they have been assessed as chemically dependent.36 We looked at
counties’ 2003-04 assessment findings for clients authorized for treatment paid
for by the Consolidated Chemical Dependency Treatment Fund, and we found:
•

Among counties, the percentage of clients assessed as “dependent”
ranged from 45 percent to 100 percent.

Statewide, counties assessed 84 percent of clients authorized for publicly-funded
treatment as chemically dependent, with the other 16 percent assessed as
chemically abusive.37 But, among counties, there were considerable differences
in the assessment findings for clients. Table 3.6 shows the variation in
assessment results for select counties and regions of the state during the two-year
period. While it is reasonable to expect some variation in counties’ assessment
findings, the differences discussed here provide further evidence of inconsistency
in counties’ assessment practices. Such differences may contribute to unequal
access, because abuse and dependency determinations directly affect the types of
treatment for which persons are eligible.

American Society of Addiction Medicine, Inc., ASAM Patient Placement Criteria for the
Treatment of Substance-Related Disorders, 2nd ed. revised, ed. David Mee-Lee (Chevy Chase, MD:
ASAM, 2001).
34

Staff in one county mentioned several adolescent-specific instruments that they often use to
supplement standard interviews, and staff in another county said that they require at least one
parent to be present during adolescent assessments.
35

Miller, Westerberg, and Waldron, “Evaluating Alcohol Problems in Adults and Adolescents,” 82.

Minnesota Rules 2005, 9530.6630, subp. 1, and 9530.6640.

Local agencies do not report information to the Department of Human Services on the number of
clients who were not referred to treatment following an assessment.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Table 3.6: Assessment Results of Clients Authorized
for Publicly-Funded Treatment, Select Counties,
2003-04

Region/County

Number of Clients
Authorized for
Treatment Paid for
by the Consolidated
Chemical
Dependency
Treatment Fund
(CCDTF)

Percentage of
CCDTF Clients
Assessed as
Chemically
Dependent

Percentage of
CCDTF Clients
Assessed as
Chemically
Abusive

Statewide

30,302

84%

16%

Twin Cities Metro Area
Carver
Scott
Ramsey
Washington
Anoka
Hennepin
Dakota

17,817
224
301
3,819
757
1,190
10,583
943

84
95
92
90
90
87
82
69

16
5
8
10
10
13
18
31

Outstate

12,485

Counties with Highest Rate
of “Dependent” Clientsa
Martin
LeSueur
Freeborn
Meeker

182
154
164
105

98
97
96
95

2
3
4
5

Counties with Lowest Rate
of “Dependent” Clientsa
Mower
Morrison
Douglas
Beltrami

331
168
215
416

64
63
62
55

36
37
38
45

NOTE: Analysis represents only those clients who were assessed and authorized for treatment paid
for by the Consolidated Chemical Dependency Treatment Fund. Assessment results include clients
assessed by county agencies only, and exclude clients assessed by tribal agencies. Clients and
assessment results were included for each county in which a client was assessed and authorized for
CCDTF-funded treatment during 2003-04.
a

Counties with more than 100 residents assessed and authorized for CCDTF-funded treatment.

SOURCE: Office of the Legislative Auditor’s analysis of Department of Human Services’ Client
Placement Authorization data.

Assessment Recommendations
Minnesota’s regulations for substance abuse treatment are changing. New state
rules governing chemical dependency treatment programs took effect in January
2005, eliminating the “level of care” categories that have often been used to
categorize programs (inpatient treatment, outpatient treatment, halfway houses,
and extended care). DHS staff regard the new treatment rule as “client-focused”
rather than “program-focused”—that is, encouraging programs to tailor services
to individual needs, rather than the previous approach of trying to “fit” clients

SUBSTANCE ABUSE TREATMENT
into distinct program categories. Under the rule, treatment programs are
expected to continuously monitor client progress (using the “dimensions” shown
in Table 3.7) and adjust treatment accordingly.

DHS plans to
implement new
rules in 2007 for
assessing clients
prior to their
referral to
treatment.

Meanwhile, the department is drafting new rules for pre-referral chemical use
assessments. These rules, which are scheduled to take effect in January 2007,
would require counties, tribes, and prepaid health plans to assess clients’ risks in
each of the areas shown in Table 3.7. The rules specify services that must be
provided for persons at various risk levels.38 Local assessors would still have
considerable latitude in determining what specific information to obtain from
clients to make judgments about placement.

Table 3.7: Client “Dimensions” that Substance Abuse
Treatment Providers Must Assess
1.
2.
3.
4.
5.
6.

Potential for acute intoxication and withdrawal
Biomedical conditions and complications
Emotional and behavioral conditions and complications
T
reatment acceptance and resistance
Potential for relapse and continued substance use
R
ecovery environment

SOURCE: Minnesota Rules 2005, 9530.6422, subp. 2.

The department’s efforts to develop new assessment rules have considerable
support among local officials with whom we spoke. However, we think there are
several issues that state policy makers and administrators should address to
improve client assessments and referrals.
RECOMMENDATIONS

To provide more consistency in assessment practices, the Department of
Human Services should:
• Distribute information to chemical health assessors on “best practices”
in assessments, including model instruments for adults and
adolescents; and
• Monitor the compliance of local agencies with assessment and referral
rules.
There is considerable support within the chemical dependency and corrections
fields for the use of standardized or “semi-structured” assessment instruments, to
help ensure that assessments (1) identify symptoms that are relevant for purposes
of diagnosis, placement, and treatment planning, (2) do not overlook important
38

For example, for clients with low motivation for change and passive involvement in treatment
(risk level 2 on the “treatment acceptance and resistance” dimension), the draft rules require that
treatment include “engagement strategies” (which are undefined).

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

client characteristics, and (3) result in reasonably consistent findings by different
assessors.39 In several counties we visited, staff said that they would welcome
guidance from the Minnesota Department of Human Services regarding “model”
instruments for chemical use assessment.

DHS should
provide guidance
to counties on
good assessment
methods, and it
should monitor
actual assessment
and referral
practices.

We do not recommend that the department or Legislature mandate the statewide
implementation of a single assessment instrument. But we think that the
department should provide ongoing guidance to help assessors understand the
strengths and weaknesses of various assessment methods. In late 2005, the
Department of Human Services hired a consultant to prepare a report discussing
the most promising assessment tools for substance abuse in adolescents. It is too
early to know how the department will use this information, but these efforts
were a good first step. We think the department should help counties identify
model instruments for adult assessments, too. Similarly, the department could
provide guidance on particular assessment components (such as assessment of
clients’ mental health status), or ways to assess clients that are sensitive to age,
gender, or cultural characteristics. The department told us that it intends to
incorporate guidance on assessment practices into its 2006 statewide training
related to the implementation of new assessment rules.
We also think that the Department of Human Services should fulfill its statutory
obligation to oversee local assessment and referral processes. Increased state
oversight would promote consistency. Rule 25 assessments play a key role in
local decisions regarding who will be referred to treatment services that are
funded largely by the state, yet the state does not actively monitor these
assessments. Just as the department now reviews treatment programs’
compliance with state licensing rules, the department should monitor local
compliance with state assessment rules.
RECOMMENDATION

The Department of Human Services should develop a directory that
identifies key characteristics of each licensed chemical dependency
treatment program.
In our view, the appropriateness of client placements could be enhanced if local
agencies had more information about the state’s licensed treatment programs.
There are nearly 300 treatment programs in Minnesota and, as of January 2005,
they are no longer distinguished by labels such as “primary treatment” (inpatient
or residential care), “outpatient treatment,” “extended care,” and “halfway
house.” These labels have been a centerpiece of the state’s placement criteria,
but assessors will now need to rely on their knowledge of differences in
programs’ content. Assessors often gain a working understanding of the
programs in their regions, but some county staff told us that they would welcome
39
For example, U.S. Department of Health and Human Services, Treatment for Alcohol and Other
Drug Abuse: Opportunities for Coordination (Washington, D.C., 1994) says that substance abuse
assessment instruments should be evaluated for validity and reliability. Also, Re-Entry Policy
Council, Charting the Safe and Successful Return of Prisoners to the Community, (New York,
2004), 133, encourages “the use of only validated screening and assessment instruments in the
intake procedure.”

SUBSTANCE ABUSE TREATMENT
additional information. As discussed in Chapter 1, there is no statewide directory
of substance abuse treatment programs that indicates the types of treatment
approaches the programs use or which optional services they provide. Such a
directory could also indicate which programs have specialized staff (such as
psychologists or other mental health staff), on-site housing, and “case
management” services for ongoing client monitoring. This information may help
local agencies ensure that clients are receiving appropriate types of services, in
the proper setting, and for the right duration.
Also, an inventory of treatment programs could help state and local agencies
exercise program oversight. For example, it could help these agencies identify
gaps in services, or determine whether existing services are consistent with
research-based treatment practices (such as those discussed in Chapter 2).
Descriptions of program characteristics could also help state and local officials to
differentiate programs when they analyze client outcomes.
RECOMMENDATION

To address concerns about the timeliness and thoroughness of assessments,
the Legislature should amend state law:
• To clarify responsibility for chemical use assessments of persons jailed
outside their home counties; and
• To require that chemical use assessors interview the probation officers
of persons on probation.

State law should
be amended to
help ensure timely
chemical use
assessments of
persons in jail.

DHS’ draft assessment rules would establish timeframes in which Rule 25
assessments must be conducted.40 However, the draft rules do not directly
address what happens in cases where clients are taken into custody by law
enforcement outside their home counties. Some local chemical dependency
officials told us their agencies do not have sufficient resources to travel to other
counties’ jails to conduct assessments. Without provisions for these inter-county
cases, the stipulation of assessment deadlines in the new rules might not fully
address problems with assessment timeliness. In our view, a preferable approach
is the one specified in law for chemical use assessments of convicted impaired
drivers. For such persons, the assessment must be conducted by the home county
within a statutorily-specified period, or else the county where the person will be
sentenced must conduct the assessment and bill the home county.41
In addition, we think that assessors should be required to contact probation
officers when assessing the chemical health of persons on probation. This would
help to address concerns that some Rule 25 assessments rely too much on selfreported information. We think that the impaired driving statutes again provide a
useful model, as they require assessors of convicted impaired drivers to make

The draft rules specify that, for any client “seeking treatment or for whom treatment is sought,”
the client must be interviewed within 15 calendar days from the date an appointment was requested,
and the assessment must be completed within 7 days of the initial interview.

Minnesota Statutes 2004, 169A.70, subd. 4.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

“collateral contacts” with probation officers (for offenders who have them).42
There is no such requirement in statute or rule for Rule 25 assessments.43
RECOMMENDATION

The Legislature should consider amending state law to prohibit Rule 25
assessors from having financial conflicts of interest with treatment
providers, except in circumstances that are now specified in state rules.

State laws and
rules should have
consistent
provisions
regarding
conflicts of
interest for people
who conduct
chemical use
assessments.

In most counties we visited or contacted, Rule 25 assessments are usually done
by county assessment staff in a social services or probation agency. In some
cases, however, counties contract with private organizations to conduct
assessments, and some of these organizations also provide substance abuse
treatment.
Currently, state rules governing chemical use assessments prohibit counties from
contracting with assessors who have a “direct shared financial interest or referral
relationship resulting in shared financial gain with a treatment provider,” except
in certain cases specified in the rules.44 The Department of Human Services has
proposed eliminating language regarding conflict of interest from the assessment
rules.45 However, state law still prohibits such conflicts of interest in chemical
use assessments that are conducted as part of offenders’ pre-sentence
investigations.46 Also, state law prohibits such conflicts in chemical use
assessments of impaired drivers, and these statutory provisions reference the rule
language that DHS proposes to eliminate.47 We think that it would be confusing
and contradictory to have differing requirements regarding conflicts of interest
for different types of chemical use assessments. Thus, before DHS proceeds with
adoption of proposed rules during the coming year, we suggest that the
Legislature consider amending Minnesota Statutes chapter 254A to include the
conflict of interest provisions that are now in the existing rules. Alternatively, if
the Legislature does not wish to adopt these provisions into law for Rule 25
assessments, it should consider repealing the statutory conflict of interest
provisions that now apply to pre-sentence investigations and impaired driver
assessments.

Laws of Minnesota 2005, chapter 136, art. 18, sec. 9.

Also, it would be a good practice for probation officers to regularly share relevant information
with assessors about offenders that the officers (or courts) have referred for assessment, rather than
waiting for the assessors to initiate this contact.
44
Minnesota Rules 2005, 9530.6610, subp. 3. The rules authorize exceptions to this general
provision, if the county can document that (1) the assessor provides “culturally specific” services or
provides services designed for individuals of a particular age, sex, or sexual preference, or (2) it
does not employ enough qualified assessors, and the only available assessor in the county has
financial interests with a treatment provider.
45

DHS staff told us that such conflicts of interest are less common than they used to be, and
counties have been made aware of the risks of such arrangements. Also, DHS staff noted that
counties, not assessors, have the ultimate responsibility for making client placements.

Minnesota Statutes 2004, 609.115, subd. 8(b).

Minnesota Statutes 2004, 169A.70, subd. 4.

SUBSTANCE ABUSE TREATMENT

AVAILABILITY OF SUBSTANCE ABUSE
TREATMENT
One of the National Institute on Drug Abuse’s principles of effective substance
abuse treatment is that treatment needs to be readily available. According to the
institute,
Because individuals who are addicted to drugs may be uncertain about
entering treatment, taking advantage of opportunities when [the
individuals] are ready for treatment is crucial. Potential treatment
applicants can be lost if treatment is not immediately available or is not
readily accessible.48
In July 2005, there were 280 licensed substance abuse treatment programs in
Minnesota. We found that:
•

The number of non-residential treatment programs in Minnesota
grew in recent years, while the number of residential programs
remained fairly stable.

Table 3.8 shows that the number of licensed non-residential programs grew from
113 in 2000 to 188 in 2005, a 66 percent increase. Non-residential programs are
not licensed for a specified capacity, so it is hard to determine precisely what
impact the program increase had on the availability of non-residential treatment
“slots.” Meanwhile, the number of residential programs and their total licensed
capacity did not change much from 2000 to 2005, although there were minor
fluctuations during this period.49

Table 3.8: Licensed Substance Abuse Treatment
Programs, 2000-05
Number of Programs:

Year

Licensed

Capacity of

Residential

Programs

Residential

Non-Residential

Total

2000
2001
2002
2003
2004
2005

2,882
3,021
3,045
3,171
3,228
2,974

91
96
99
99
100
92

113
121
141
159
177
188

204
217
240
258
277
280

NOTE: Program counts are as of July 1 each year.
SOURCE: Office of the Legislative Auditor’s analysis of data from Department of Human Services.

National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based
Guide (Washington, D.C., 1999), 1.

49
Programs in the seven-county Twin Cities area accounted for 46 percent of the state’s total

number of licensed programs and 47 percent of the residential capacity in 2005. These seven

counties had an estimated 54 percent of Minnesota’s population in 2004.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

In the sections below, we examine local perceptions regarding treatment
availability, the extent to which persons are admitted to treatment outside their
home counties, trends in the state’s public treatment funding, and the extent to
which persons sentenced to probation for felony offenses have entered
community-based treatment.

Local Perceptions About Treatment
Availability

Local officials
have particular
concerns about
the availability of
treatment in
halfway houses
and extended care
programs.

Substance abuse treatment in the community is often a part of multi-pronged
efforts by courts and corrections agencies to hold offenders accountable and
encourage rehabilitation, so we conducted a statewide survey of communitybased corrections directors.50 Also, during site visits to eight counties, we
interviewed county human services officials about the availability of substance
abuse treatment for the broad range of clients served by their agencies. In many
cases, the comments we heard from human services officials echoed the concerns
that were documented more systematically in our corrections survey.
We asked the corrections directors to rate their satisfaction with the availability
of community-based programs that are (1) of adequate quality, and (2) within a
reasonable distance of the offenders their agencies supervise. Table 3.9
summarizes the survey findings for various “levels of care,” as defined in state
rules prior to 2005. First, we found that:
•

Corrections officials expressed more satisfaction with the availability
of inpatient and outpatient treatment programs in their regions than
with halfway houses and extended care programs.

In the case of services for adults, more than 60 percent of corrections directors
expressed satisfaction with the availability of inpatient and outpatient options,
while only about one-third of the directors were satisfied with the availability of
other levels of care.
Second, Table 3.9 indicates that:
•

Corrections officials tended to be more dissatisfied with the
availability of treatment programs for adolescents than for adults.

In each of the four levels of care shown in the table, a higher percentage of
corrections directors expressed dissatisfaction with the availability of services for
adolescents compared with adults. The director of a corrections agency serving
offenders in several western Minnesota counties said: “Quality programming…
is virtually non-existent in our area for juvenile offenders.” Another county
corrections director expressed similar concerns: “Adolescent outpatient services
have been virtually non-existent in Southeast Minnesota….” Meanwhile, human
50

Criminal offenders account for a significant share of Minnesota’s treatment admissions,
according to data reported to DHS by treatment providers. For example, in 2004, 41 percent of
Minnesota admissions to publicly-funded, community-based substance abuse treatment were for
persons (1) with a criminal or juvenile court order to treatment at the time of admission, or (2) for
whom the primary reason for treatment was reported as a condition of probation or parole, or the
client’s choice instead of going to jail.

SUBSTANCE ABUSE TREATMENT

Table 3.9: Local Corrections Directors’ Views
Regarding Treatment Availability, by Level of Care
There is
considerable
dissatisfaction
with the
availability of
adolescent
treatment in all
levels of care.

Level of Care

Percentage of Corrections Directors Who Were:
Neither
Satisfied nor
Satisfied
Dissatisfied
Dissatisfied

Adults
Residential or inpatient
Outpatient
Halfway houses
Extended care

61%
69
37
30

26%
13
45
45

13%
19
18
25

Adolescents
Residential or inpatient
Outpatient
Halfway houses
Extended care

46%
42
33
20

38%
38
50
57

16%
20
17
23

NOTE: The “satisfied” category in this table includes those who responded “satisfied” or “very
satisfied” on the survey. The “dissatisfied” category in this table includes those who responded
“dissatisfied” or “very dissatisfied.” Persons who responded “not applicable” were excluded from the
calculations.
SOURCE: Office of the Legislative Auditor’s survey of directors of community-based corrections
agencies, September 2005 (N=54).

services staff in St. Louis County noted that there has never been a substance
abuse treatment program on the Iron Range (in northeastern Minnesota) that
serves adolescents.
In addition, Table 3.10 shows correctional directors’ satisfaction with treatment
availability for particular categories of offenders. The table shows that directors
were somewhat more satisfied with treatment options for male offenders than for
female offenders, both for adults and adolescents. In addition, the table shows
that:
•

For both adults and adolescents, local corrections and human
services officials reported little satisfaction with services for persons
with (1) “dual diagnoses” of mental illness and chemical dependency,
and (2) persons with cognitive limitations.

Persons with substance abuse problems often have mental health problems, too.
A national study found that, among persons with a current drug use disorder who
sought treatment in the previous 12 months, 60 percent had at least one mood
disorder that was not substance-induced.51 However, Table 3.10 shows that only
19 percent of Minnesota’s community-based corrections directors said they were

Bridget F. Grant, Frederick S. Stinson, Deborah A. Dawson, Patricia Chou, Mary C. Dufour,
Wilson Compton, Roger P. Pickering, and Kenneth Kaplan, “Prevalence and Co-occurrence of
Substance Use Disorders and Independent Mood and Anxiety Disorders: Results From the
National Epidemiologic Survey on Alcohol and Related Conditions,” Archives of General
Psychiatry 61 (August 2004): 807-816. For persons with a current alcohol use disorder who
sought treatment in the previous 12 months, the comparable figure was 41 percent.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Table 3.10: Local Corrections Directors’ Views
Regarding Treatment Availability for Certain Offender
Groups
Type of Offender

Percentage of Corrections Directors Who Were:
Neither Satisfied
nor Dissatisfied
Satisfied
Dissatisfied

Adults
• Males

77%

11%

• Females

• With dual diagnoses of mental
health and chemical dependency
problems

• With developmental disabilities or
brain injuries

• With alcohol abuse or dependence

• With amphetamine abuse or
dependence

• Males

• Females

• With dual diagnoses of mental

health and chemical dependency

problems

• With developmental disabilities or

brain injuries

• With alcohol abuse or dependence

• With opiate abuse or dependence
Adolescents

• With amphetamine abuse or

dependence
• With opiate abuse or dependence

NOTE: The “satisfied” category in this table includes those who responded “satisfied” and “very
satisfied” on the survey. The “dissatisfied” category in this table includes those who responded
“dissatisfied” and “very dissatisfied” on the survey. Persons who responded “not applicable” were
excluded from the calculations.
SOURCE: Office of the Legislative Auditor’s survey of directors of community-based corrections
agencies, September 2005 (N=54).

satisfied with the availability of treatment for adults with dual diagnoses of
substance abuse and mental health problems, and only 10 percent were satisfied
with such treatment options for adolescents. Local human services officials told
us that many counties’ mental health and chemical dependency services are
poorly integrated, and that some chemical dependency treatment programs are

SUBSTANCE ABUSE TREATMENT
ill-equipped to address serious mental health problems. According to one county
chemical dependency director, some counties have been reluctant to spend their
chemical dependency funds to address the mental health needs of chemically
dependent persons.

It is too early to
judge the impact
of new rules
intended to
improve services
to clients
diagnosed with
both chemical
dependency and
mental health
problems.

In 2005, the Department of Human Services adopted new substance abuse
treatment rules that, among other things, were intended to improve services to
clients with “dual diagnoses” or “co-occurring disorders.” Under the rules, all
chemical dependency treatment programs are required to assess clients for co
occurring disorders and integrate services for these disorders into the clients’
service plans, when applicable. Also, the rules require licensed treatment
programs’ chemical dependency counselors, nurses, supervisors, and directors to
meet a minimum level of training in mental health disorders.52 The department
provided 12 hours of free training to about 1,200 chemical health professionals
prior to implementation of the rule, and the 12-hour course is now offered for a
fee by the Minnesota State Colleges and Universities system. In our view, the
new rules are a step in the right direction, especially in light of the views of
corrections officials cited above. It is too early, however, to judge whether the
rules will significantly improve services and outcomes for clients with dual
diagnoses.
Local corrections and human services officials also said that it is difficult to find
substance abuse treatment for persons with developmental disabilities or brain
injuries. For this population, certain treatment programs may not be appropriate,
such as those that focus on thinking skills or expect participants to offer insights
about their problems. For both adults and adolescents, less than 10 percent of the
corrections directors we surveyed expressed satisfaction with treatment options
for persons with cognitive limitations.
In addition, Table 3.10 indicates that:
•

Corrections directors reported far less satisfaction with the
availability of treatment for amphetamine abuse than for alcohol
abuse.

For adults, 81 percent of corrections directors said they were satisfied with the
availability of appropriate treatment options for persons with alcohol-related
problems. In contrast, only 9 percent were satisfied with treatment for persons
with amphetamine-related problems. As the director of one outstate Minnesota
corrections agency said:
The lack of a "continuum" of treatment for meth offenders is very
problematic. Best practices [have] shown that these offenders first need
a longer amount of time to simply detoxify (typically in the jail setting)
followed by extended care primary treatment, then halfway house and
then aftercare services. The chemical dependency assessors and
treatment centers, until recently, did not seem to understand that need. If
the offender is actively using meth and is not in a position to detoxify in
jail before entering treatment, the first [part] of traditional "treatment"

Minnesota Rules 2005, 9530.6422, 9530.6430, and 9530.6460.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

[is] a waste of funding. However, there is no other alternative available
at this time.53
Some county human services staff said that it has become more difficult to find
available beds in treatment programs in recent years, partly due to the influx of
methamphetamine users in programs. In addition, some officials expressed a
desire for more treatment programs that specialize in serving methamphetamine
users, even if the programs use similar treatment approaches to other programs.
For example, human services staff in Olmsted County became frustrated by the
repeated failure of methamphetamine users in existing treatment programs, so
they designed new programs specifically for methamphetamine users who are
criminal offenders.54

The 2005
Legislature
authorized grants
to foster
appropriate
treatment for
methamphetamine
users.

The 2005 Legislature appropriated $1.5 million to the Department of Public
Safety for the fiscal year 2006-07 biennium for methamphetamine treatment
grants. The Legislature instructed the department to give priority to counties
“that demonstrate a treatment approach that incorporates best practices as defined
by the Minnesota Department of Human Services.”55 Following the issuance of a
request for proposals, the Department of Public Safety selected five county
organizations in December 2005 to receive grants.56
Finally, we asked corrections directors about their satisfaction with several other
types of community-based services for chemically dependent offenders under
their supervision. As shown in Table 3.11, the most significant area of
dissatisfaction was the availability of housing options for chemically dependent
persons, such as “sober houses” for persons who are attending outpatient
treatment. In addition, many corrections directors expressed dissatisfaction with
the availability of aftercare services for persons who completed treatment in
prison-based or community-based programs. If the directors’ perceptions about
the lack of such services are correct, this is contrary to the state’s policy
supporting a continuum of services for persons leaving treatment programs.57

In many cases, persons who have used methamphetamines have impaired cognitive skills and
require more sleep in the period immediately following discontinuation of use. This presents
special challenges if the persons are immediately assigned to treatment programs that require active
participation.
54
Olmsted has a short-term education program (14 hours) that is provided to offenders in jail. It is
a “warm-up” for a longer-term program that typically provides more than 100 hours of communitybased treatment per offender over the course of a year. Staff said that the long-term program
combines elements of cognitive-behavioral, 12-step, and skills-building treatment approaches.
55

Laws of Minnesota 2005, chapter 136, art. 1, sec. 9, subd. 6.

The proposals receiving funding were from Dodge-Fillmore-Olmsted Community Corrections
and the human services agencies in Carlton, Anoka, Sherburne, and Faribault-Martin counties.
57

Minnesota Statutes 2004, 254A.01.

SUBSTANCE ABUSE TREATMENT

Table 3.11: Local Corrections Directors’ Views on the
Availability of Treatment-Related Services
Local officials
have significant
concerns about
the availability of
housing and
aftercare options
for chemically
dependent
persons.

Percentage of Corrections Directors Who Were:

Type of Service or Treatment
Housing specifically for chemically
dependent persons (e.g., “sober
houses”)
Aftercare following prison-based
treatment
Aftercare following communitybased treatment
Case management services to help

offenders access social services
Random drug or alcohol testing

Satisfied

Dissatisfied

Neither

Satisfied nor

Dissatisfied

91%

33
69

38
20

NOTE: The “satisfied” category in this table includes those who responded “satisfied” and “very
satisfied” on the survey. The “dissatisfied” category in this table includes those who responded
“dissatisfied” and “very dissatisfied” on the survey. Persons who responded “not applicable” were
excluded from the calculations. For the question regarding aftercare following prison-based
treatment, we excluded the responses of directors whose agencies do not supervise adult felons
(thus, N=29).
SOURCE: Office of the Legislative Auditor’s survey of directors of community-based corrections
agencies, September 2005 (N=54).

Treatment Placements Outside Residents’
Home Counties
Another measure of the availability of substance abuse treatment is the extent to
which persons receive treatment outside their counties of residence. On one
hand, it may be therapeutic for some treatment participants to attend programs
that are far removed from their normal environments. Also, some programs
attract clients from considerable distances due to their strong reputations. But, on
the other hand, clients may sometimes enter distant treatment programs because
there are limited or no options closer to home. In addition, placements far from
home can make it more difficult for treatment staff to work with family members
or foster supportive relationships for the client following treatment.58 As a
director of a county probation agency commented to us, “People need family
support—shipping our people away doesn’t fix what our clients will go back to.”
We examined the extent to which persons whose treatment was paid for by the
Consolidated Chemical Dependency Treatment Fund attended treatment
programs outside their counties of residence. We found that:

58
Minnesota Statutes 2004, 254A.01, establishes a state policy of including family members as
soon as possible in the treatment process.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY
•

About 51 percent of publicly-funded admissions to substance abuse
treatment in 2004 were at programs located outside of the clients’
home counties.

Persons entering outpatient substance abuse treatment were much more likely to
remain in their home counties for care than were persons entering other types of
treatment. Among CCDTF-funded clients from Minnesota who entered
outpatient treatment in 2004, 27 percent of admissions were to programs outside
the clients’ home counties. In contrast, the percentages of out-of-county
admissions for other levels of care were 69 percent for inpatient treatment, 63
percent for halfway houses, and 85 percent for extended care.59

Many counties
rely entirely on
programs in other
counties to
provide certain
levels of care to
their residents.

Many counties relied entirely on out-of-county treatment programs to provide
certain levels of care, as shown in Table 3.12. The table shows that all of the
persons admitted to inpatient treatment in 2004 from 60 of Minnesota’s 87
counties entered programs outside their home counties. Similarly, for a large
majority of counties, all residents who entered halfway houses or extended care
programs did so at programs outside their home counties. The complete absence
of in-county admissions in certain levels of care appears to indicate that residents
did not have such treatment options within their counties. For example, as one
corrections director from southwestern Minnesota commented in our survey:
“[One of my counties] has outpatient services only. [The other county] has no
treatment services available. We are needing to send clients for inpatient
treatment to locations several hours away or to other states.”

Table 3.12: Number of Counties With All Treatment
Admissions Provided Outside of Clients’ Counties of
Residence, by Level of Care
Level of Care
Inpatient
Outpatient
Halfway houses
Extended care

Number of Counties for Which All 2004
Admissions of County Residents to This Level of
Care Occurred Outside County of Residence
60
2
4
69
67

NOTE: This table includes all clients who entered treatment, including both publicly- and privatelyfunded clients.
SOURCE: Office of the Legislative Auditor’s analysis of Department of Human Services’ Drug and
Alcohol Abuse Normative Evaluation System data.

59
Based on Office of the Legislative Auditor analysis of the Department of Human Services’ Drug
and Alcohol Abuse Normative Evaluation System data.

SUBSTANCE ABUSE TREATMENT

Availability of Methadone Maintenance
Programs
Methadone maintenance is a type of substance abuse treatment for opiate (mainly
heroin) addicts, and Chapter 2 reported that this treatment has positive results, on
balance, when properly managed. Treatment participants go to licensed clinics to
receive daily oral doses of methadone, a synthetic substance that relieves
symptoms of opiate addiction. We found that:
•

Some opiate users
regularly travel
long distances to
obtain methadone
treatment.

Only two methadone maintenance programs serve publicly-funded
clients, and they operate near capacity.

Minnesota has a total of seven outpatient programs that are licensed by the
Department of Human Services to operate methadone programs, but the only two
programs that serve CCDTF clients are located in Hennepin County.60 Because
of the limited number of methadone programs, some opiate addicts regularly
travel long distances within Minnesota to obtain methadone. To reduce the
amount of home-to-clinic travel by methadone users, the Department of Human
Services can authorize individual clients who live far from clinics to obtain up to
seven daily doses of methadone per weekly visit.61
As of late 2005, the two programs authorized to serve publicly-funded clients
accounted for half of the 2,200 authorized treatment “slots” in Minnesota’s
methadone clinics.62 Since the beginning of 2003, these two clinics have
consistently operated at or above 90 percent capacity.63 Department of Human
Services staff told us that they have been unable to persuade counties to enter
additional contracts with methadone clinics to serve publicly-funded clients.
They said that officials in many counties object to the idea of using a drug to treat
drug users.

Public Funding For Treatment
Since it started in 1988, the Consolidated Chemical Dependency Treatment Fund
(CCDTF) has been Minnesota’s primary source of public funding for substance
abuse treatment. CCDTF combines federal and state revenue sources. In
addition, state law requires counties to pay for a portion of CCDTF-funded
treatment. To qualify for publicly-funded treatment, individuals must meet stateprescribed income eligibility standards. We found that:

60
There are four programs that only serve private-pay clients because the programs do not have a
contract with a “host county” to serve CCDTF-funded clients. In addition, a small program run by
the Veterans Administration only serves military veterans.
61

As of mid-November 2005, DHS had authorized nearly 500 clients during 2005 to receive
multiple doses during individual visits to their clinics.
62

The total number of authorized slots increased from about 1,600 in 2001 to 2,200 in late 2005.
Based on a review of reports filed with the Department of Human Services, we estimated that the
two CCDTF clinics filled 97 percent of their authorized slots between January 2003 and August
2005. During this period, the state’s other methadone clinics filled 89 percent of their slots.
Programs have occasionally operated over 100 percent of capacity, probably due to staffing
fluctuations.
63

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY
•

State law
establishes three
tiers of eligibility
for publiclyfunded treatment,
but only one tier is
presently funded.

The income limit for persons eligible for state chemical dependency
treatment funding has declined in recent years, but the number of
persons receiving publicly-funded treatment has increased.

State law establishes three tiers of eligibility for CCDTF-funded treatment, as
shown in Table 3.13. Persons in “Tier 1” are (1) eligible for Medical Assistance,
General Assistance Medical Care, or Minnesota Supplemental Assistance, or (2)
have household incomes at or below the federal poverty line. By law, persons
who meet the “Tier 1” criteria are entitled to CCDTF-funded treatment. In
contrast, state law says that persons within the “Tier 2” and “Tier 3” income
ranges shall be eligible for CCDTF-funded treatment “within the limit of funds
appropriated for this group for the fiscal year.”64 The Legislature discontinued
Tier 3 funding in 1991, and it discontinued Tier 2 funding in 2003.

Table 3.13: Consolidated Chemical Dependency
Treatment Fund Eligibility

Funding Tier
1
2
3

Household Income Limit
(Percentage of Federal
Poverty Guidelines)
100%a
215
412

Are Eligible Clients
Entitled to Funding?

Is Funding
Appropriated for This
Tier in the 2005-07
Biennium?

Yes
No
No

Also, persons eligible for Medical Assistance, General Assistance Medical Care, or Minnesota
Supplemental Assistance are CCDTF-eligible, regardless of income.
SOURCE: Minnesota Department of Human Services, Bulletin: DHS Updates CCDTF Operations,
Eligibility for State Fiscal Year 2006 (St. Paul, July 27, 2005).

The maximum income of persons eligible for CCDTF funding declined sharply
when Tier 2 funding was discontinued. For example, the maximum qualifying
income for a single person with no children dropped from $19,066 in fiscal year
2003 to $8,988 in fiscal year 2004. For a person in a household of three, the
maximum qualifying household income dropped from $32,302 to $15,264 during
this period.65
Although the elimination of Tier 2 funding significantly restricted individuals’
eligibility for publicly-funded treatment, the state’s total appropriation to CCDTF
has grown. Figure 3.1 shows that, unadjusted for inflation, appropriations to the
fund increased from $37.2 million in fiscal year 2000 to $63.2 million in fiscal

64
65

Minnesota Statutes 2004, 254B.04, subd. 1.

Minnesota Department of Human Services, Bulletin: DHS Updates CCDTF Operations,
Eligibility for State Fiscal Year 2003, June 28, 2002, and Bulletin: DHS Updates CCDTF
Operations, Eligibility for State Fiscal Year 2004, June 26, 2003. In January 2004, before funding
for Tier 2 was eliminated, DHS tightened Tier 2 eligibility due to funding limitations.

SUBSTANCE ABUSE TREATMENT

Figure 3.1: State Appropriations (in Millions) for
Consolidated Chemical Dependency Treatment Fund,
FY 2000-06
Total state
appropriations
for chemical
dependency
treatment have
increased.

$63.2
$60.0

$49.3
$44.5

$43.9

2001

2002

$45.2

$37.2

2000

2003

2004

2005

2006

NOTE: Dollar amounts are not adjusted for inflation.
SOURCE: Minnesota Department of Human Services.

year 2006.66 Adjusted for inflation, state appropriations grew by 17 percent
between 2000 and 2004, and during this period the annual number of individuals
served by CCDTF increased by 19 percent.67
The Minnesota Department of Human Services administers annual allocations
from the CCDTF to each county, based on a complex statutory formula that takes
into account the county’s population, welfare eligibility, and median income for
married couples. Figure 3.2 summarizes the three phases of financial
responsibility for the treatment costs of individuals who meet the CCDTF
criteria. During a fiscal year, a county initially pays 15 percent of individuals’
treatment costs, until its annual CCDTF allocation is spent. Then, the county
pays 100 percent of treatment costs, until it has met its statutorily-required

Department of Human Services staff told us that the Legislature increased appropriations mainly
due to projected increases in demand for services. In addition, they said, the state had to repay the
federal government in the current biennium for prior cases in which federal funds paid for chemical
dependency services that should have been paid by state funds.

67
We adjusted for inflation using the federal government’s implicit price deflator for state and local
government expenditures. The unduplicated number of individuals authorized for CCDTF-funded
treatment grew from 15,477 in 2000 to 18,281 in 2002. The number declined to 17,040 in 2003
(when eligibility restrictions took effect), and then increased to 18,414 in 2004.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Figure 3.2: Financial Responsibility for PubliclyFunded Substance Abuse Treatment
PHASE 1:
CCDTF share: 85%

(Until the base CCDTF
allocation is used)

County share: 15%

The share of
treatment costs
paid by a county
depends on
whether it has
exhausted its state
funding allocation
and met its
“maintenance of
effort”
requirement.

PHASE 2:
CCDTF share:

(Until the local
“maintenance of effort”
requirement is met)

County share: 100%

PHASE 3:
CCDTF share: 85%
(from reserve)
County share: 15%

SOURCE: Minnesota Statutes 2004, chapter 254B.

“maintenance of effort.” After this, a CCDTF “reserve account” pays 85 percent
of treatment costs, and the county pays the remaining 15 percent.68
The “maintenance of effort” requirement is a key determinant of an individual
county’s financial responsibility for treatment costs. State law defines the
“maintenance of effort” amount as “the amount of local money used for eligible
services in calendar year 1986,” adjusted in subsequent years in proportion to
changes in state appropriations for the CCDTF.69 The “maintenance of effort”
requirement was originally intended to discourage counties from reducing their
own spending in response to increases in state appropriations for CCDTF.
However, we observed that:

Also, counties may choose to pay the full cost of treatment for any clients who are deemed
ineligible for CCDTF, and such spending counts toward their “maintenance of effort.”
69
Minnesota Statutes 2004, 254B.02, subd. 3. For counties that provide Medical Assistance or
General Assistance Medical Care through managed care plans, the base year for determining the
“maintenance of effort” level used in the funding allocation process was fiscal year 1995 or the
subsequent year in which the county started its managed care.

SUBSTANCE ABUSE TREATMENT
•

There are significant differences among counties in their financial
responsibility for the cost of publicly-funded substance abuse
treatment, partly reflecting longstanding statutory provisions that
have questionable relevance today.

In 2004, the percentage of treatment costs paid by individual counties ranged
from the statutory minimum of 15 percent (38 counties) to 36 percent
(Washington County). There was even greater variation in the “maintenance of
effort” requirements faced by individual counties, which may influence actual
county spending levels. Counties’ 2004 “maintenance of effort” levels, as a
percentage of their CCDTF allocations, ranged from a low of 4 percent (Big
Stone County) to 70 percent (Washington, Hennepin, and Mahnomen counties).
The following example is illustrative of the differing provisions:

Some counties can
leverage more
state funding than
others, due
to differences
in their
“maintenance
of effort”
requirements.

Anoka and Dakota counties are suburban Twin Cities area counties with
similar numbers of residents and similar CCDTF base allocations.70
However, Anoka’s required local “maintenance of effort” ($284,000, or
15 percent of its base allocation) was much lower than Dakota’s
“maintenance of effort” ($858,000, or 49 percent of its base allocation),
reflecting Anoka’s lower county spending for chemical dependency
treatment in the mid-1980s. Anoka could meet its entire “maintenance of
effort” requirement with its payments of 15 percent of treatment costs
during “Phase 1” of the fiscal year (see Figure 3.2). The county could
then skip Phase 2 (100 percent county financial responsibility for
treatment costs) and move directly to Phase 3, where most treatment
costs are covered by the CCDTF reserve.71 In contrast, if Dakota
County were to use up its 2004 CCDTF base allocation, it would then be
solely responsible for another $500,000 in treatment costs before it
would be eligible to receive CCDTF reserve funding.
The differences among counties’ “maintenance of effort” requirements mean that
some counties’ local expenditures can leverage more CCDTF dollars than other
counties’ local expenditures. This does not necessarily mean that counties with
higher “maintenance of effort” requirements make fewer placements into
treatment. In fact, we found little relationship between counties’ “maintenance
of effort” requirements and their utilization rates for publicly-funded treatment.72
In other words, counties that were expected to pay for larger shares of treatment
due to high “maintenance of effort” requirements did not necessarily make fewer
publicly-funded placements per 1,000 low-income residents; in fact, they
sometimes made more placements.

70
Anoka was eligible for a CCDTF base allocation of $1.90 million in 2004, and Dakota was
eligible for an allocation of $1.77 million.
71

In 2004, Anoka was 1 of 35 counties that could meet their entire annual “maintenance of effort”
requirement by paying the 15 percent county match for their annual base level CCDTF allocation
(Phase 1 in Figure 3.2).
72
We examined the relationship between counties’ 2004 maintenance of effort (as a percentage of
the counties’ base allocations) and their number of publicly-funded 2003-04 adult admissions per
1,000 adults in poverty. The correlation of these two variables was +0.30, indicating that higher
maintenance of effort was modestly associated with higher placement rates.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

Participation in Treatment by Offenders on
Probation

Criminal
offenders are
more likely than
other persons to
rely on public
funding to pay for
substance abuse
treatment.

In general, criminal offenders are more likely than non-offenders to rely on
public funding to pay for treatment. For example, CCDTF paid for 49.5 percent
of the substance abuse treatment admissions of persons with criminal court
orders who entered treatment in 2004, compared with 41.5 percent of admissions
of persons without court orders who entered treatment.73 In our statewide survey
of directors of community-based corrections agencies, we asked about the role of
the Consolidated Chemical Dependency Treatment Fund in paying for treatment
of offenders under their supervision. We found that:
•

Criminal offenders’ eligibility for publicly-funded treatment often
affects whether they participate in treatment, according to many
probation directors.

About 85 percent of the directors estimated that chemically dependent offenders
who were deemed eligible for CCDTF-funded services “always,” “almost
always,” or “usually” entered substance abuse treatment. In contrast, only 32
percent of the directors estimated that chemically dependent offenders who were
not eligible for CCDTF funding “always,” “almost always,” or “usually” entered
treatment. Thus, if the 2003 Legislature’s elimination of Tier 2 CCDTF funding
made some offenders ineligible for publicly-funded treatment, this may have
adversely affected their likelihood to participate in treatment.
We examined the extent to which persons who were sentenced to probation for
drug or alcohol offenses entered treatment in the community. We selected a
representative random sample of persons sentenced by Minnesota courts in 2003
for felony-level crimes involving possession or use of drugs or alcohol.74 Using
Department of Human Services data on treatment admissions, we looked for
evidence that these offenders entered a licensed treatment program in the
community between (1) their offense date, and (2) a date six months after their
sentencing date or their last possible date in jail.75 We found that:
•

In 2003, 46 percent of felony-level drug or alcohol offenders
sentenced to probation in the community did not enter substance
abuse treatment in their pre-sentence period or in the period
immediately following their sentencing.

Office of the Legislative Auditor analysis of Department of Human Services Drug and Alcohol
Normative Evaluation System data.
74
Using data from the Minnesota Sentencing Guidelines Commission, we selected a random
sample of 340 offenders who were sentenced in 2003. A sample of this size enabled us to be 95
percent sure that the statewide percentage of persons who entered treatment was within 5
percentage points of what we measured using the sample population (assuming that the treatment
data were complete).
75

Among the offenders in our sample, the average period of time for which we looked for evidence
of participation in treatment was 529 days. We did not have information on the “conditions of
probation” set by the sentencing judges in these cases, but we assumed that persons sentenced for
felony-level drug and alcohol crimes would be more likely than lower-level offenders to be ordered
to treatment.

SUBSTANCE ABUSE TREATMENT
Within our sample, persons sentenced for driving under the influence of alcohol
or other drugs were the most likely group to enter treatment (66 percent), while
persons sentenced for powder cocaine offenses were the least likely probationers
to enter treatment (37 percent). Forty-two percent of the offenders sentenced to
probation in our sample completed a treatment program during the time period
we examined.
We did not fully explore the reasons why the drug and alcohol offenders in our
sample did not enroll in treatment. Perhaps courts or probation officers did not
direct some of the offenders to treatment. Maybe other offenders could not
afford treatment, refused to participate in treatment, moved out of state, or were
incarcerated for new crimes or probation violations. But, whatever the reasons,
we think it is reasonable to expect a higher percentage of felony-level drug and
alcohol offenders to enter treatment before or immediately following sentencing.

Treatment Availability Recommendations
RECOMMENDATION

DHS should present the 2007 Legislature with a plan for improving the
availability of community-based substance abuse treatment in Minnesota.

DHS should
increase its efforts
to foster new
treatment services
to address clients’
needs.

The availability of substance abuse treatment varies around the state. In some
locations, Minnesota lacks the range of programs or services to effectively meet
the needs of different types of clients. State law designates the Minnesota
Department of Human Services as the lead agency for coordinating chemical
dependency services in Minnesota. For example, the law requires the department
to establish a state plan that sets forth goals and priorities for a “comprehensive”
approach to addressing substance abuse.76 We think that DHS should help the
Legislature to consider possible strategies for improving the availability of
substance abuse treatment for low income persons, hard-to-serve populations,
and criminal offenders. The department has made some previous efforts to
improve existing services.77 Still, we think that treatment availability remains an
important issue, and the department should increase its efforts to foster the
development of new programs that can effectively address clients’ needs (or to
improve existing programs). This may require additional expenditures in some
(but not necessarily all) cases, and DHS should seek additional funding, if
necessary.
To help contain human services expenditures at a time when the state faced a
large budget shortfall, the 2003 Legislature restricted eligibility for publiclyfunded treatment so that only the lowest income clients (“Tier 1”) qualified. We
think that DHS’ plan for improving service availability should discuss the merits
76
77

Minnesota Statutes 2004, 254A.03.

For example, the department has issued a request for proposals for a methadone maintenance
program in outstate Minnesota. Also, the department has sponsored training in methamphetamine
treatment (in 2004 and 2005), and it has provided training on several substance abuse treatment
approaches identified by the U.S. Department of Health and Human Services as “model” programs.

COMMUNITY-BASED TREATMENT: USE AND AVAILABILITY

of various options, including the possibility of Tier 2 funding, at least for certain
client subgroups (such as adolescents, or criminal offenders ordered by the courts
to participate in treatment).
RECOMMENDATION

The Department of Human Services, with input from local officials, should
report to the 2007 Legislature on the merits of changing the statutory
“maintenance of effort” provisions of the Consolidated Chemical
Dependency Treatment Fund.

DHS should
examine options
for changing the
state’s chemical
dependency
treatment funding
formula.

The CCDTF funding formula is one of several factors that may affect the access
of individuals around the state to treatment. At a minimum, it affects the costs
that local agencies face to provide treatment services to their residents. Although
a complete review of the CCDTF formula was beyond the scope of our
evaluation, we noted earlier that individual counties’ level of treatment spending
in the 1980s provides a starting point in the current funding formula for
determining the local share of financial responsibility for treatment costs. We
question whether this is still appropriate. Local spending patterns prior to the
implementation of the Consolidated Chemical Dependency Treatment Fund in
1988 may have reflected a very different system of treatment placement and
financing options. For example, a county in which a state hospital was located
could have made many of its substance abuse placements at the hospital, mostly
at state expense, while other counties’ treatment options may have involved
greater county expense per placement.
The Department of Human Services recently established a task force of state and
local officials to examine the formula and consider the need for possible statutory
changes. We support this effort and suggest that the department assess options
for changes and their possible impacts.
RECOMMENDATION

The Department of Human Services should work with the Department of
Health to develop guidelines and training materials for health care
organizations on the use of “brief interventions” for alcohol abuse.

State officials
should encourage
the use of “brief
interventions” by
health care
professionals.

In Chapter 2, we summarized selected findings from research literature on the
effectiveness of substance abuse treatment. We cited a recent research summary
that reported that “brief interventions” have shown strong evidence of
effectiveness among various approaches for persons who abuse alcohol. Such
interventions could be provided by doctors, nurses, or other health care
professionals, and they do not involve the longer-term counseling and skillbuilding that is a part of licensed treatment programs. “Brief interventions” are
perhaps best used as part of a prevention strategy, rather than as a substitute for
intensive treatment.
We do not know the extent to which Minnesota health care agencies now use
“brief interventions,” but staff with the Minnesota Department of Human

SUBSTANCE ABUSE TREATMENT
Services told us they do not recall activities by their agency to encourage the
implementation or effective use of “brief interventions” for adults.78 We think
the department should foster their use, given that (1) alcohol is the most common
substance abused by persons entering treatment in Minnesota, and (2) the
research evidence on “brief interventions” is relatively strong.

78
For adolescents, DHS has developed the Adolescent Health Review, a screening instrument to
help primary care providers identify behavioral health issues.

Community-Based
Treatment: Outcomes
and Program Oversight
SUMMARY

There are limited data on the outcomes of Minnesota’s community-based
substance abuse treatment programs. A majority of persons complete the
programs they enter, but the length of treatment is often shorter than
experts recommend. It is common for people to have more than one
admission to treatment, although frequent readmissions have not been the
norm. Many local officials think that community-based treatment services
should be better tailored to clients’ needs, especially clients with mental
health problems. To help local agencies make appropriate decisions about
client placements, the Department of Human Services should provide more
information on treatment program outcomes, compliance with state
regulations, and overall quality.

olicy makers regularly pose questions about the adequacy of Minnesota’s
substance abuse treatment programs. Chapter 2 noted that it is challenging to
definitively measure the impact of treatment, but this chapter addresses the
following questions:
•

Are treatment services sufficiently tailored to meet clients’

individual needs?

•

Do clients receive sufficient amounts of treatment, as measured by
the length of time in treatment and the extent to which they complete
their programs?

•

To what extent do clients have repeated admissions to communitybased treatment, and should policy makers be concerned about
readmissions?

•

Do agencies that place clients in treatment have sufficient
information about the programs’ performance and outcomes?

ADDRESSING INDIVIDUAL NEEDS
To help ensure better client outcomes, there is general support within the
substance abuse treatment profession for the principle of tailoring services to the
needs of individual clients. For example, the National Institute on Drug Abuse
said that this is “critical to [clients’] ultimate success in returning to productive

SUBSTANCE ABUSE TREATMENT
functioning in the family, workplace, and society.”1 Clients who receive
inadequate services may be more likely to relapse.
State rules require individual assessments of persons before and after placement
in publicly-funded treatment.2 The rules also require treatment providers to
develop individual treatment plans that set forth treatment goals and methods.
These plans, which “must continually be updated” to reflect new priorities and
needs, address the amount, frequency, and anticipated duration of treatment.
Treatment methods “must be appropriate to the client’s language, reading skills,
cultural background, and strengths,” and treatment services “must address
cultural differences and special needs of all clients.”3

Treatment
programs develop
plans for each
client, but some
local officials
think programs
should do more to
tailor services to
individual needs.

These requirements do not necessarily ensure that treatment is, in fact, modified
to meet client needs. We found that:
•

Directors of community-based corrections agencies expressed mixed
views about the extent to which treatment programs tailor their
services to meet individual needs, and they had particular concerns
about the adequacy of programs’ mental health services.

In response to our statewide survey, 47 percent of corrections directors said that
substance abuse treatment programs “always,” “almost always,” or “usually”
tailor their services to meet client needs. Meanwhile, 53 percent of corrections
directors said that programs “sometimes,” “rarely,” or “never” do so, including
six of seven directors in the Twin Cities metropolitan area (which accounts for
about half of the state’s admissions of offenders to treatment).
We also asked corrections directors whether the needs of offenders they
supervise would be better addressed if treatment programs gave more or less
emphasis to certain types of programming. Table 4.1 shows their responses.
Among the services shown, the highest percentage (96 percent) of directors
favored more efforts by substance abuse treatment programs to address
offenders’ mental health needs. In addition, a majority of directors thought that
offenders’ needs would be addressed more effectively with more cognitivebehavioral treatment (87 percent), more efforts to enhance client motivation (85
percent), more efforts to improve clients’ suitability for employment (81
percent), and more marital or family therapy (54 percent). In contrast, a majority
of corrections officials said they did not see a need for more abstinence-based
treatment programs, spiritually-based treatment activities, 12-step treatment
programs, or programs that allow controlled use of alcohol.
Because mental health services were a significant concern among corrections
officials and some of the county human services staff with whom we spoke, it is
worth reiterating (as discussed in Chapter 3) that administrative rules
implemented in January 2005 require all licensed substance abuse treatment
1

National Institute on Drug Abuse, Principles of Drug Addition Treatment: A Research-Based
Guide (Washington, D.C., 1999), 1.

Minnesota Rules 2005, 9530.6615, subp. 1, and 9530.6422, subp. 1. Treatment providers must
conduct comprehensive assessments within three days of initiating services for a client.

Minnesota Rules 2005, 9530.6425 and 9530.6430, subp. 1.

COMMUNITY-BASED TREATMENT: OUTCOMES AND PROGRAM OVERSIGHT

Table 4.1: Local Corrections Directors’ Preferences
for Greater or Lesser Use of Certain Treatment
Approaches
Nearly all
corrections
directors said
treatment
programs should
make greater
efforts to address
clients’ mental
health issues.

Percentage of Corrections Directors Who Said:

Treatment Approach or Type of Service
Efforts to address clients’ mental health
needs
Use of cognitive-behavioral treatment
Efforts to enhance client motivation to
successfully complete treatment
Efforts to help clients improve their
suitability for employment
Marital or family therapy
Expectations that clients will maintain
complete abstinence from alcohol
Spiritually-based activities
Expectations that clients will control,
but not necessarily eliminate, their
alcohol use
Use of the “12-step” treatment model

Need
More

No
Change
Needed

Need
Less/Fewer

Don’t
Know

96%
87

2%
11

0%
0

2%
2

81
54

17
37

2
2

0
6

32
20

55
52

8
11

6
17

21
12

44
68

19
10

17
8

SOURCE: Office of the Legislative Auditor’s survey of directors of community-based corrections
agencies, September 2005 (N=54). Persons who responded “not applicable” were excluded from the
calculations.

programs to provide “services to address issues related to co-occurring mental
illness.”4 The new rules represent the Department of Human Services’ attempt to
ensure better integration of mental health services into substance abuse programs,
with a goal of improving clients’ treatment outcomes.5

LENGTH OF TREATMENT
Programs differ in the intensity and content of the services they provide over a
given period of time, so the duration of treatment is only one factor that affects
program outcomes. Still, we noted in Chapter 2 that there is an emerging
consensus in the substance abuse field that persons with addictions often require
services over an extended period of time, even if some of those services are
provided infrequently or at low levels of intensity. The National Institute on
Drug Abuse has stated that “remaining in treatment for an adequate period of
time is critical for treatment effectiveness” and that: “Generally, for residential
4
5

Minnesota Rules 2005, 9530.6430, subp. 1.

Treatment providers should not bear full responsibility for ensuring that services are properly
tailored to individual needs; this is also the responsibility of local agencies that make treatment
referrals. One county corrections agency expressed concern to us that its county human services
agency routinely alternates referrals between the county’s two treatment providers—with one
referral to the first provider, the next to the second provider, the next to the first provider, and so
on. Corrections staff questioned whether this resulted in the best services for individual offenders.

SUBSTANCE ABUSE TREATMENT
or outpatient treatment, participation for less than 90 days is of limited or no
effectiveness, and treatments lasting significantly longer often are indicated.”6
However, we found that:
•

The National
Institute on Drug
Abuse says
treatment should
generally last at
least 90 days to be
effective.

The duration of chemical dependency treatment is typically shorter
than that recommended by national experts.

Table 4.2 shows that, for people who completed publicly-funded treatment in
2004, the average duration per admission was less than 90 days, regardless of the
level of care.7 We also looked at the duration of treatment after taking into
account those instances in which individuals transferred directly from one type of
treatment to another. For example, sometimes persons move from inpatient to
outpatient care as a planned sequence in their treatment regimen. Thus, for a
sample of offenders sentenced to probation in 2003 who subsequently entered
community-based treatment, we identified each person’s longest continuous
“episode” of treatment.8 We found that only 29 percent of the 183 “treated”
probationers were in community-based treatment for a cumulative period of at
least 90 days. Also, we examined the treatment history of a sample of about 400
persons discharged from treatment in 2004, and only 22 percent of the
continuous treatment “episodes” for these persons between 1995 and 2004 were
for periods of 90 days or more.9

Table 4.2: Average Duration of Publicly-Funded
Treatment for Treatment “Completers,” 2004
Treatment Level of Care
Inpatient/Residential
Outpatient
Halfway House
Extended Care
Totalb

Average Days in
Treatment per Admissiona

Number of Completers

27.3
58.5
85.6
60.4
52.7

4,280
5,928
1,833
1,124
13,289

NOTE: Based on admissions of Minnesota residents to publicly-funded treatment in 2004 who were
coded by treatment providers as having completed their treatment program.
a

Represents average total days elapsed between treatment admission and discharge.

Includes 124 admissions for treatment reported in two other level-of-care categories (combined
inpatient and combined outpatient).
SOURCE: Office of the Legislative Auditor’s analysis of Department of Human Services’ Drug and
Alcohol Normative Evaluation System data.

National Institute on Drug Abuse, Principles of Drug Addiction Treatment, 1, 14.

Some people leave treatment before they have completed the treatment provider’s full regimen, or
before they have completed the amount of treatment recommended bv county officials. Including
non-completers in the analyses in this section would reduce the average length-of-stay.

We identified the longest continuous treatment episode that started between the date of the
criminal offense and a date six months subsequent to sentencing. If a person left one program and
entered another within 30 days, we added the total days in the first program (between admission
and discharge) to the total days in the second program. Thus, we did not count days between
treatment stays in our calculations of the length of treatment episodes.
9
If a person in this sample entered a treatment program within 30 days of leaving another program,
we counted the days of care from both placements as part of a single “episode” of treatment.

COMMUNITY-BASED TREATMENT: OUTCOMES AND PROGRAM OVERSIGHT

In addition, we found that:
•

The average duration of chemical dependency treatment in

Minnesota has grown shorter in recent years, especially for

inpatient/residential treatment and “extended care.”

Figure 4.1 shows statewide trends for various levels of care, based on all
admissions to publicly- and privately-funded treatment that resulted in a
completed program. Since 2000, the average length of treatment for clients in
inpatient/residential care declined by 36 percent, from 35.4 days to 22.8 days.10
During this period, the declines in average length-of-stay for other types of
treatment were 6 percent for outpatient care, 12 percent for extended care, and 3
percent for halfway houses. Among program completers, the overall average
length of treatment per admission declined from 55 days in 2000 to 48 days in
2004 (13 percent).

The average
length of inpatient
treatment
declined 36
percent between
2000 and 2004.

Figure 4.1: Average Length (in Days) of Completed
Treatment per Admission, 2000-04
100

2000

2001

2002

2003

2004

0
Inpatient/Residential

Outpatient

Halfway House

Extended Care

Level of Care

SOURCE: Office of the Legislative Auditor’s analysis of data from the Department of Human
Services’ Drug and Alcohol Normative Evaluation System data.

We also examined comparable trends for persons who entered treatment
primarily due to amphetamine use. Some researchers and public officials
contend that methamphetamine addicts need longer treatment than other persons,
due to longer periods of detoxification and the longer cognitive effects of the
drug. We found reductions between 2000 and 2004 in the average duration of
10

Our analysis of the length of treatment was based on the total number of days between clients’
dates of admission and discharge. This analysis did not count consecutive treatments (where an
admission was within 30 days of a discharge) as part of a single “episode” of treatment.

SUBSTANCE ABUSE TREATMENT
completed treatment for amphetamine users in all categories of care:
inpatient/residential care (from 56 days in 2000 to 25 days in 2004), outpatient
care (from 58 to 53 days), halfway houses (from 91 to 86 days), and extended
care (from 75 to 62 days).11
Finally, from our survey of directors of community-based corrections agencies,
we found that:
•

A majority of probation directors favored longer treatment
programs for persons who abused amphetamines, cocaine, opiates,
and multiple substances.

As Table 4.3 shows, 98 percent of the directors favored longer programs for
adults who abused amphetamines, and 96 percent favored longer programs for
adolescents who abused amphetamines. In contrast, most corrections officials
did not favor longer treatment programs for persons who abused alcohol.

Many corrections
directors would
prefer longer
treatment
programs for
substance
abusers.

Table 4.3: Local Corrections Directors’ Preferences
for Changes in Treatment Program Duration
Percent of Directors Who Said They Preferred:
Offender Type (Age,
Substance of Abuse)

Longer
Programs

No Change

Shorter
Programs

Percent Who
Responded
“Don’t Know”

Adults
Amphetamines
Multiple substances
Cocaine
Opiates
Marijuana
Alcohol

98%
89
72
65
37
31

2%
7
19
20
59
65

0%
0
0
0
0
0

0%
4
9
16
4
4

Adolescents
Amphetamines
Multiple substances
Cocaine
Opiates
Marijuana
Alcohol

96
90
66
56
52
40

2
4
21
24
42
54

0
0
0
0
2
2

2
6
13
20
4
4

Among program completers, there was a 20 percent decline between 2000 and 2004 in the
overall average length-of-stay for persons whose main substance of abuse was amphetamines.

COMMUNITY-BASED TREATMENT: OUTCOMES AND PROGRAM OVERSIGHT

PROGRAM COMPLETION RATES
In 2000, a Minnesota Department of Human Services research report concluded
that “treatment completion is the most consistent predictor of abstinence [in the
six months following treatment].”12 The report said this was true for both adults
and adolescents, in all levels of care.
Clearly, it is a preferable outcome for a client to complete treatment or transfer
from one program to a complementary one. We found that:
•

In 2004, 61 percent of persons who entered publicly-funded

treatment “completed” their programs, while 31 percent left

programs “without staff approval.”13

Completion rates varied by level of care, partly reflecting differences in clients’
average length-of-stay. For example, 67 percent of publicly-funded clients who
entered inpatient treatment in 2004 completed these programs, which had the
shortest average duration among Minnesota’s main levels of care. In contrast,
the completion rates for publicly-funded clients in other levels of care were 60
percent for outpatient treatment, 61 percent for extended care, and 50 percent for
halfway houses.

Variation in
completion rates
is partly due to
differences in the
nature of the
programs and the
clients they serve.

Even within these level-of-care categories, there was considerable variation in
clients’ completion rates at individual treatment programs. For example, among
the individual programs that discharged at least 50 publicly-funded clients from
outpatient treatment in 2004, we found that the client completion rates ranged
from 26 percent to 83 percent.14
Variations in completion rates may reflect the unique circumstances of individual
programs and the difficulty of the clients they serve, according to treatment
administrators with whom we spoke. For example, one program with a high
completion rate serves offenders who are required to participate in treatment to
remain eligible for work release from the county jail, so the offenders have strong
incentives to comply with the program. Staff at another program attributed its
high completion rate to (1) the program’s nurturing atmosphere, and (2) the fact
that successful completion of the program is a prerequisite for some clients to
reunite with their children. In contrast, staff from a program with a low
completion rate said that the program’s limited resources (one counselor) and
12

Minnesota Department of Human Services, The Challenges and Benefits of Chemical
Dependency Treatment: Results From Minnesota’s Treatment Outcomes Monitoring System, 1993
1999 (St. Paul, 2000), 3. The report also said that one reason that research has linked better
outcomes to longer treatment is that short stays often occur in cases where treatment is not
completed (p. 38).
13

Most of the other discharges were due to client transfers to other programs, but there were also
discharges due to clients being assessed as inappropriate for a program, expiration of civil
commitments or hold orders, deaths, and loss of financial support.

This was based on CCDTF-funded clients only. In a similar analysis, we also counted clients
who were discharged because of “transfer to another program” as program “completers,” reflecting
the fact that some programs are specifically intended to provide an initial phase of treatment in
preparation for a transfer to another phase. Among individual programs that discharged at least 50
clients in 2004, the combined rate of completion and transfer ranged from 32 percent to 93 percent.

SUBSTANCE ABUSE TREATMENT
low intensity (one hour of treatment per week) make it difficult to adequately
address the needs of its impoverished clientele. Staff from another program with
a low completion rate said that many of its clients have serious physical and
mental health disabilities, which often limit their program participation and
employment prospects. Overall, we think that program completion rates are a
potentially valuable measure of program performance, but they should also be
interpreted with care.
Local corrections officials are mostly satisfied with the efforts treatment
programs have made to ensure that clients complete their programs. In our
survey, 79 percent of the directors of community-based corrections agencies said
that treatment programs “always,” “almost always,” or “usually” take reasonable
steps to help ensure that offenders complete the programs they begin.15
However, several directors cited concerns about programs that, in their view,
have been too hasty to discharge clients who have relapsed or violated program
rules.

READMISSIONS TO TREATMENT

The basic goal of
treatment is to
help clients
change their
behaviors.

Persons who enter substance abuse treatment have a range of drug and alcohol
problems, and their patterns of recovery also vary. Some people maintain long
periods of sobriety following treatment. For others, chemical dependency is a
chronic health problem, characterized by frequent relapses.16 Nevertheless, a
goal of substance abuse treatment is to help clients reduce their chemical use or
abstain altogether. Program counselors try to help clients change their behaviors
while in treatment and equip them to maintain sobriety following treatment. For
this reason, many studies have looked at clients’ readmission to treatment as one
indicator of treatment’s success.
Readmission rates are an imperfect measure of treatment effectiveness because
some persons who relapse following treatment do not re-enter treatment. Not all
relapses are serious enough to warrant readmission to treatment, and some clients
may have difficulty accessing appropriate treatment. In addition, readmissions
could occur because of factors other than the failure of a treatment program.17
Despite such limitations, we think that readmission rates provide useful
information on post-treatment outcomes. Also, data on readmissions are more
readily available to public agencies than measures of clients’ ongoing sobriety
and general well-being.

Office of the Legislative Auditor survey of directors of community-based corrections agencies,
September 2005 (N=54). Twenty-one percent of directors said that treatment programs
“sometimes,” “rarely,” or “never” take reasonable steps to ensure that offenders complete their
programs.

Researchers have noted similarities between the relapse rates of chemical dependence and
chronic illnesses such as diabetes, hypertension, and asthma—see A. Thomas McLellan, David C.
Lewis, Charles P. O’Brien, and Herbert D. Kleber, “Drug Dependence, A Chronic Medical Illness:
Implications for Treatment, Insurance, and Outcomes Evaluation,” Journal of the American
Medical Association 284, no. 13 (October 4, 2000): 1689-1695. The authors cite evidence that 40
to 60 percent of clients return to active substance use within a year following treatment discharge.
17

Keith Humphreys and Kenneth R. Weingardt, “Assessing Readmission to Substance Abuse
Treatment as an Indicator of Outcome and Program Performance,” Psychiatric Services 51, no. 12
(December 2000): 1568-1569.

COMMUNITY-BASED TREATMENT: OUTCOMES AND PROGRAM OVERSIGHT

We found that:
•

Many clients
enter treatment
more than once,
but frequent
readmissions are
not typical.

Among persons over age 30 discharged who completed treatment in
2004, more than one-third had no history of treatment in the
previous decade, and about one-fifth had at least four prior
admissions.

Using data reported to DHS by treatment providers, we examined the treatment
history since 1995 of nearly 400 persons over age 30 who completed substance
abuse treatment in Minnesota in late 2004.18 As shown in Figure 4.2, 37 percent
of our sample had no treatment episodes in Minnesota prior to the one that ended
in 2004, and another 22 percent had a single prior episode.19 In addition, 21
percent had two or three prior treatment episodes since 1995, and 20 percent had
four or more. Thus, while most of the clients we tracked had some prior
admissions to treatment, frequent readmissions were not the norm. Among
individuals in our sample, the most prior episodes of treatment in the ten-year
period was 14, and the most time spent in treatment cumulatively was 2.5 years.20
Some policy makers have asked about the frequency with which individuals have
been admitted to publicly-funded treatment. Thus, we examined the extent to
which persons authorized in 2004 for publicly-funded treatment had previous
authorizations for publicly-funded treatment (since 1995).21 Again, we limited
our analysis to persons who were over age 30 by the end of 2004. We found that,
among persons placed in publicly-funded treatment in 2004, 39 percent had no
prior placements in publicly-funded treatment in Minnesota during the previous
ten years, while 17 percent had been authorized for publicly-funded treatment at
least four previous times.
We found no accepted benchmarks in substance abuse literature for “normal”
rates of readmission to substance abuse treatment. The fact that a majority of
“treated” individuals had a history of just one or two episodes of treatment does

We selected a representative random sample of individuals who had completed an episode of
care in 2004 that was publicly-funded. Our analysis of prior treatments included all providerreported episodes of care, whether publicly- or privately-funded, during the previous ten years. We
could not determine instances in which clients’ names changed over time, or instances in which
treatment programs inaccurately or incompletely reported data to the Department of Human
Services, so our analysis may understate the true readmission rate.
19

If persons entered a treatment program within 30 days of leaving another program, we did not
count these as separate “episodes” of treatment.

In our sample of persons who completed treatment in 2004, rates of prior admissions for clients
whose primary substance of dependency was alcohol were somewhat higher than rates for users of
other substances. For example, 33 percent of alcohol users had no record of prior treatment
episodes during the previous ten years, 22 percent had one prior episode, 24 percent had two or
three prior episodes, and 22 percent had four or more. In contrast, 43 percent of other persons in
our sample had no prior treatment episodes, 22 percent had one prior episode, 18 percent had two
or three prior episodes, and 17 percent had four or more.
21
This analysis was based on “client placement authorizations” by counties and tribes. These
authorizations are reported to the Department of Human Services for clients whose local
assessment led to an authorization for treatment paid for by the Consolidated Chemical
Dependency Treatment Fund. Clients sometimes have more than one treatment admission resulting
from a single authorization, but generally multiple admissions are part of a planned sequence (or
“episode”) of care.

SUBSTANCE ABUSE TREATMENT

Figure 4.2: Number of Prior Treatment Episodes for
Persons Who Completed Community-Based
Treatment in 2004
Percentage of 2004 Treatment Completers (Age 30+)
37.4

22.0

12.4
8.6

7.1
4.0

2.3

2.8

3.5

Number of Prior Treatment Episodes

NOTE: Prior treatment episodes are those that occurred between 1995 and 2004, not including the
episode of treatment that was completed in late 2004. If a person entered treatment within 30 days of
discharge from another program, we counted these treatments as part of a single “episode” of care.
SOURCE: Office of the Legislative Auditor’s analysis of sample data from the Department of Human
Services’ Drug Abuse and Alcohol Normative Evaluation System.

not prove that treatment has been effective. However, for policy makers
concerned about the extent to which individuals re-enter publicly-funded
treatment, the data indicate that it is not typical for individuals to have large
numbers of repeat placements in publicly-funded treatment.

DHS should
help local
agencies identify
strategies for
handling cases
involving repeat
placements.

Counties may not refuse to place clients in treatment who have been through
treatment repeatedly.22 But counties sometimes try different approaches with
clients who have had prior placements. For example, Stearns and Dakota
counties have funded staff to work intensively with caseloads of chronic
substance abusers. Some counties consider alternatives to intensive treatment for
chronic clients, such as board-and-lodging facilities or short-term relapse
prevention programs. County human services agencies sometimes consult with
additional people before authorizing “repeat” placements, such as mental health
and probation staff. We think that decisions regarding services to persons who
have previously been through publicly-funded treatment should be made with
special care, to help ensure that appropriate options have been considered.
RECOMMENDATION

The Department of Human Services should provide local agencies with
examples of “best practices” for addressing the needs of persons being
considered for “repeat” placements into publicly-funded treatment.
22
Minnesota Statutes 2004, 254A.01, says that “treatment shall not be denied on the basis of prior
treatment.”

COMMUNITY-BASED TREATMENT: OUTCOMES AND PROGRAM OVERSIGHT

EXTERNAL REVIEWS OF TREATMENT
PROGRAMS
The outcomes of chemical dependency treatment depend considerably on the
performance of individual treatment programs. In this section, we discuss
oversight of these programs by local and state agencies and by peer reviewers.

County Oversight of Treatment Programs
State law requires that county boards, with the approval of the DHS
commissioner, “select eligible vendors of chemical dependency services who can
provide economical and appropriate treatment.”23 Counties enter into “host
county” contracts with treatment programs and negotiate payment rates for
treatment services.
State laws and rules do not prescribe specific “quality control” activities that
counties must undertake to ensure appropriate services. We interviewed human
services staff in eight counties and found that:
•

Counties have
limited
information on
treatment
outcomes.

Most counties we visited do not regularly conduct in-depth quality
assurance reviews of the treatment providers they use, and many
have limited information on program outcomes.

Staff in the two largest counties (Hennepin and Ramsey) each review samples of
client files at least once a year for each of the main treatment programs with
which the counties contract. The purpose of these reviews is to monitor whether
the programs are appropriately serving the clients referred to them. Staff in the
other counties we visited said that they do not conduct systematic file reviews on
a regular basis, or they review client records only in response to concerns raised
about a particular program.24 One county’s chemical dependency staff told us
they did not know whether they have legal authority to review individual clients’
treatment records.
Most counties we visited collect limited or no information regarding treatment
outcomes. Three counties told us that they regularly monitor program-specific
information on the extent to which clients complete the programs they start, and
one of these counties has negotiated completion rate goals with each of its
programs.25 One county’s contracts with treatment programs require the
programs to provide biweekly progress reports to the county on each client
served. Another county’s contracts require treatment providers to collect selfreported information from clients regarding their post-treatment chemical use,

Minnesota Statutes 2004, 254B.03, subd. 1(b).

Some county officials told us that their chemical dependency staff see client records during
ongoing contacts with treatment programs, so they have not seen a need to schedule separate
“quality assurance” reviews.
25

The goals have differed among programs, depending on their “level of care” and the types of
clients they serve.

SUBSTANCE ABUSE TREATMENT
family relationships, employment status, arrests, and “quality of life.”26 In
addition, DHS provides all counties with periodic reports on the characteristics of
their residents entering treatment, but most counties said these reports have been
of limited use for evaluating treatment services.27

Recent changes in
state rules may
present new
challenges for
monitoring client
progress.

Recent changes to the state’s rules for substance abuse treatment could present
new challenges as local agencies try to monitor client progress. As we discussed
in Chapter 3, the new rules are intended to promote more individualized
treatment for clients. Terms previously used in state rules to categorize treatment
programs (inpatient, outpatient, extended care, and halfway houses) have been
eliminated, which places more responsibility on counties to understand
differences in programs’ content, or to explain variations in programs’ outcomes.
It may also be more challenging for counties to hold treatment programs
accountable as some programs evolve from standardized treatment approaches
toward more individualized services.
We think that DHS should identify “best practices” for county oversight of
services. This should include ways to monitor individual client progress, as well
as ways to monitor overall program outcomes. In addition, DHS can help foster
improved oversight by providing counties with additional information on client
outcomes, such as program completion rates and client readmission rates
(especially for clients in publicly-funded treatment). This information could help
local agencies make more informed decisions about client placements.
RECOMMENDATIONS

The Department of Human Services should identify “best practices” to help
local agencies monitor the progress of the clients they place in treatment.
The department should periodically provide these agencies with statewide
information on treatment outcomes.
Also, to the extent possible, DHS should insure the integrity of data distributed to
local agencies. DHS staff told us they have had some concerns about the
completeness of data reported by some treatment providers, especially for
privately-funded clients.28

This county has set target performance levels regarding the percentage of clients who remain
arrest-free and sober following treatment. The most ambitious targets are for clients from
outpatient programs, while the least ambitious targets are for clients from halfway houses.

27
DHS’ standard reports summarize information that treatment providers are required by state rules
to collect on every person entering treatment, including demographic information, chemical use
history, length-of-stay, and reasons for discharge. The only program-specific information in the
standard reports is total number of admissions. Also, the reports do not have separate information
on publicly- and privately-funded clients.
28

As a condition of eligibility for payment from the Consolidated Chemical Dependency Treatment
Fund, state rules require providers to submit information to DHS “on all individuals who are served
by the vendor” (Minnesota Rules 2005, 9530.7030).

COMMUNITY-BASED TREATMENT: OUTCOMES AND PROGRAM OVERSIGHT

Licensing Reviews and Peer Reviews

Licensing reviews
examine whether
treatment
programs are in
compliance with
state laws and
rules.

The Department of Human Services issues licenses to substance abuse treatment
programs and monitors the compliance of these programs with state and federal
regulations. During periodic site visits, the department’s licensing staff fulfill a
“quality control” function by examining programs’ policies and practices, based
partly on reviews of client records.
During each licensing review, department staff document any violations of laws
or rules that they observed. In many cases, the violations are procedural in
nature—for example, a program does not have the state-required descriptions of
its health care services, nursing services, dietary services, and emergency
physician services. In other cases, violations relate more directly to client care,
such as whether a program offers both individual and group counseling (as
required by state rules). Occasionally, the department cites facilities for
egregious violations, such as a recent case in which the department found
evidence of maltreatment by a substance abuse program, which contributed to a
resident’s death by overdose.
Figure 4.3 shows recent trends in the average number of violations found per
program reviewed.29 There was a sharp increase in the average number of
regulatory violations by treatment programs in 2005, although this does not
necessarily mean that treatment quality declined. DHS licensing staff said that
treatment providers are probably still gaining familiarity with the new licensing
requirements that took effect in January 2005. Some of these new rules
established more demanding standards than previously existed.
Besides the department’s licensing reviews, there are also periodic peer reviews
of licensed programs. As a condition of receiving federal block grant funding for
substance abuse services, Minnesota must ensure that peer reviews annually
examine at least 5 percent of the state’s licensed providers, including a
representative sample of their clients’ records.30 In addition, peer reviews must
examine the client intake process, assessments, treatment and discharge planning,
treatment services, and indicators of treatment outcomes. DHS staff randomly
select programs for review, solicit treatment staff to conduct the reviews, and
draft brief reports based on the reviewers’ findings.31
In our view, local agencies that place clients in treatment should take an interest
in the department’s licensing reviews and peer reviews, as two measures of
program performance. This is particularly true in cases where counties have

The specific programs reviewed by DHS differ from one six-month period to the next. However,
department staff thought that the programs reviewed in a given six-month period are, in aggregate,
similar to those reviewed in other periods, so they thought it was reasonable to look at trends in
programs’ average numbers of violations.

45 Code of Federal Regulations 2005, 96.136. The peer review process is intended “to assess the
quality, appropriateness, and efficacy of treatment services.”

The one-page peer review reports provide limited details but are still potentially useful. For
example, a recent review concluded that a program needed to increase its staffing levels, update its
policies, improve documentation in client records, and improve client assessments.

SUBSTANCE ABUSE TREATMENT

Figure 4.3: Average Number of Violations per
Licensed Program Reviewed, 2003-05
New licensing
rules took effect

17.3

9.7
8.7
7.6

4.6

1/03 to 6/03

7/03 to 12/03

1/04 to 6/04

7/04 to 12/04

1/05 to 6/05

Dates of Licensing Reviews

SOURCE: Office of the Legislative Auditor’s analysis of Department of Human Services’ licensing
data.

entered into “host county” contracts with programs to serve publicly-funded
clients. However,
•

DHS should make
external reviews
of treatment
programs more
accessible to
agencies that
place clients.

Most counties do not receive copies of licensing reviews and peer
reviews of substance abuse treatment programs.

DHS does not routinely provide counties with copies of its licensing reviews of
substance abuse treatment programs, and only two counties (Hennepin and
Ramsey) have specifically requested to get copies of all reviews for programs in
their counties.32 Also, during our visits to selected counties, we found that
county staff were generally unaware that peer reviews of treatment programs
were conducted, and they had not seen copies of peer review reports.
RECOMMENDATION

The Department of Human Services should post copies of state licensing
reviews and treatment program peer reviews at an online location where
they could be reviewed by agencies that make client placements.
Nonpublic information that is examined during the course of licensing reviews or
peer reviews should be protected by DHS from public disclosure. However, we
think that the final reports that summarize reviewers’ findings could provide
useful information to agencies that make client placements.
32

DHS staff told us that they routinely notify the county in which a chemical dependency program
is located only if the department issues a fine or conditional license, or if it revokes or suspends a
program’s license.

Treatment for Prisoners:
Use and Availability
SUMMARY

A large proportion of prison inmates have substance abuse problems, but
most of these inmates do not participate in treatment prior to their release
from prison. Many inmates are not imprisoned long enough to complete a
treatment program, but there is also a shortage of treatment beds for
chemically dependent offenders. In addition, few chemically dependent
offenders enroll in community-based treatment in the months following
their release from prison, and offenders’ “release plans” typically have
vague provisions regarding substance abuse services in the community.
The Department of Corrections and local corrections agencies should work
together to determine which substance abuse assessments and services are
needed by individual offenders upon release.

ffenders with substance abuse problems have been a large and growing part
of Minnesota’s population of prison inmates. The number of persons in
prison for drug-related offenses increased from 276 in 1990 to 2,178 in 2005. In
addition, many persons imprisoned for other types of offenses have histories of
substance abuse. Regardless of the prior treatment histories of these offenders, a
prison sentence provides an opportunity for corrections officials to engage
offenders in rehabilitative programs before the offenders return to the
community. In this chapter, we examine the following questions:
•

Does the Minnesota Department of Corrections (DOC) have
appropriate processes for determining inmates’ needs for substance
abuse treatment in prison?

•

Are there adequate opportunities for inmates to participate in
substance abuse treatment while in prison?

•

Is there adequate planning for services for chemically dependent
prisoners following their release from prison?

ASSESSMENT PRACTICES
Inmates who enter prison are “screened” for possible drug or alcohol problems.
As part of a broader health screening process, this screening determines which
offenders will be referred for a more detailed “assessment” of drug or alcohol

SUBSTANCE ABUSE TREATMENT
problems.1 Since 2003, the department has used the Texas Christian University
Drug Screen for its chemical health screenings of inmates. We found that:
•

The initial screening instrument used by the Department of
Corrections is considered to be a valid, accurate tool by experts in
the substance abuse field.

In 2000, a study compared the effectiveness of eight screening instruments in
detecting substance abuse disorders among prison inmates. This study identified
three instruments—including the Texas Christian University Drug Screen—as
providing the most accurate screening outcomes.2 The study reported lower
performance by the screening instrument that DOC used until 2003.

The Department
of Corrections
revised its
methods of
assessing prison
inmates in 2003.

According to DOC policy, offenders whose screenings indicate possible chemical
use problems must subsequently receive a more in-depth assessment “using a
standardized assessment instrument.”3 According to DOC policy, the assessment
should provide a “comprehensive review of chemical dependency issues,”
including the severity of the inmate’s problems and the assessor’s “diagnostic
impression.”4 Until 2003, DOC used a commercially available assessment tool
and had information regarding its reliability and validity.5 However, the
department discontinued using this instrument as a way of managing agencywide budget reductions.
Since 2003, the department has used an assessment instrument that staff
developed in-house to conduct “structured interviews” prior to decisions about
treatment referrals. While developing this instrument, DOC solicited input from
an outside consultant, the departments of Human Services and Public Safety, and
DOC’s behavioral health advisory committee. The structured interviews help
assessors obtain information from inmates that is related to professionallyrecognized diagnostic criteria for chemical dependency. The interviews are used
in combination with information collected from other sources, such as local pre
sentence investigations and the screening conducted when the inmate entered
prison.
DOC’s assessment instrument for conducting structured interviews is less
detailed than the one it used prior to 2003, and its validity and reliability are

Minnesota Department of Corrections Policies 500.050 and 500.308.

Roger H. Peters, Paul E. Greenbaum, Marc L. Steinberg, Chris R. Carter, Madeline M. Ortiz,
Bruce C. Fry, and Steven K. Valle, “Effectiveness of Screening Instruments in Detecting Substance
Use Disorders Among Prisoners,” Journal of Substance Abuse Treatment 18 (2000): 349-358.

Minnesota Department of Corrections Policy 500.308. In practice, all female inmates are jointly
screened and assessed at intake. In 2002, more than 80 percent of DOC’s male inmates were
assessed, while the others were “screened out” for having low risks for substance use problems,
according to Norman G. Hoffman, Diagnosis of Substance Use Disorders: Annual Report, 2002
(Smithfield, RI: Evince Clinical Assessments, February 2003), 2.
4

Minnesota Department of Corrections Policy 203.013.

Hoffman, Diagnosis of Substance Use Disorders: Annual Report, 2002.

TREATMENT FOR PRISONERS: USE AND AVAILABILITY

unknown.6 DOC staff acknowledged that this pre-referral assessment does not
provide enough information to develop a treatment plan, so inmates who enter
treatment receive another, more in-depth assessment. Thus, it is unclear that this
instrument meets DOC’s requirement for a “comprehensive review” of inmates’
chemical health problems prior to the issuance of a treatment directive.

The inmate
assessment
process should be
subject to periodic
independent
reviews.

DOC staff told us that they believe this instrument serves its main purpose—
specifically, helping assessors make reasonable judgments about: (1) whether an
inmate is chemically dependent or abusive, and (2) which type of program
(treatment or psycho-educational) the inmate should be referred to, if any. They
think it is reasonable to conduct the more detailed chemical dependency
assessment after an inmate enters treatment, rather than before. Perhaps the
department is correct, but we think it would be useful to have periodic
independent reviews of the content and sequence of DOC’s assessment process,
given its important role in treatment referrals.
RECOMMENDATION

The Department of Corrections should periodically obtain external reviews
of the assessment procedures it uses to determine inmates’ needs for
chemical dependency services.
At a minimum, we think that DOC should have the Department of Human
Services (DHS) review its assessment process, perhaps every two or three years.
DHS is responsible in law for monitoring “the conduct of [substance abuse]
diagnosis and referral services” in Minnesota.7 In addition, it would be useful for
DOC to have assessment experts from outside of Minnesota state government
periodically examine its practices.
DOC does not have a written policy regarding how soon a chemical use
assessment must be completed after intake, but the director of DOC’s behavioral
health services told us that her goal is to have assessments completed within 30
days.8 She estimated that, as of 2003, DOC had not met this timeframe for about
1,000 prison inmates. To address this problem, the department temporarily
assigned two central office staff to help conduct assessments. The director of
behavioral health services told us that the department has eliminated its
assessment backlog for persons newly committed to prison, but it is still working

Many assessment experts recommend that assessments incorporate instruments with proven
validity and reliability, although this depends somewhat on the purposes for which the assessment
is used. A recent national report on prison practices suggested “the use of only validated screening
and assessment instruments in the intake procedure” (see Re-entry Policy Council, Charting the
Safe and Successful Return of Prisoners to the Community (New York, 2004), 133).
7
8

Minnesota Statutes 2004, 254A.03, subd. 1.

Meeting this goal is not entirely within the department’s control, as assessors often seek
information from county agencies to supplement inmates’ self-reports.

SUBSTANCE ABUSE TREATMENT
to conduct more timely assessments of offenders returning to prison for violating
their supervised release.9

PARTICIPATION IN TREATMENT WHILE
IN PRISON
A large proportion of the offenders sentenced to prison have drug or alcohol
problems. In the nearly 4,000 prison-based assessments administered by DOC in
2004, assessors concluded that 64 percent of the subjects were “chemically
dependent,” and another 25 percent were “chemically abusive.”

While in prison,
inmates assessed
as having
substance use
problems may be
referred to
relatively short
education
programs or
longer treatment
programs.

DOC staff told us that inmates assessed to be “chemically dependent” are usually
recommended by assessors to participate in treatment programs lasting at least
six months, assuming the inmates have sufficient prison time remaining to
complete a prison-based program. For inmates assessed as “chemically abusive,”
assessors typically recommend placement in psycho-educational substance abuse
programs lasting three months or less.10
DOC policy does not authorize the chemical dependency assessors to direct
inmates to treatment. Rather, “program review teams,” appointed by wardens at
each prison, issue treatment directives on behalf of the Commissioner of
Corrections after the offenders have been assessed. DOC policy states that the
program review team “will direct all offenders who are assessed to need chemical
dependency rehabilitative treatment to participate in treatment.”11 If inmates
refuse to follow these directives, they are subject to disciplinary action (typically,
30 to 45 days of additional incarceration).12
We examined levels of inmate participation in prison-based treatment programs
for substance abuse (as distinguished from short-term substance abuse education
programs). We found that:
•

Due to expanded treatment capacity, the number of inmates enrolled
in prison-based substance abuse treatment in recent years grew
faster than the size of the state’s inmate population.

The department has not kept track over time of the number of inmates needing assessments who
have not yet received them. However, the director of behavioral health services asked prison staff
to notify her of any cases in which assessments were not completed prior to the end of the prison
intake process, and she said there have been no recent notifications regarding persons newly
committed to prison.

Minnesota Department of Corrections Policy 500.308 has more detailed guidelines regarding
which inmates should be referred to treatment, psycho-educational programs, or no program. For
example, inmates determined by assessors to be “chemically abusive” rather than “chemically
dependent” might be referred to prison-based treatment if the offenders’ chemical use directly
contributed to the offenses leading to their imprisonment. Also, inmates determined by assessors to
be “chemically dependent” but with insufficient prison time to complete a treatment program are
referred to a psycho-educational substance abuse program.

11
12

Minnesota Department of Corrections Policy 203.013.

Minnesota Statutes 2004, 244.03 authorizes the Commissioner to impose sanctions for refusal to
participate in rehabilitative programs. There are no disciplinary consequences for inmates whose
non-participation is due to a lack of beds in these programs.

TREATMENT FOR PRISONERS: USE AND AVAILABILITY

In recent years,
admissions to
prison-based
treatment
programs grew
more slowly than
admissions to
education
programs.

Annual admissions to Minnesota’s prison-based substance abuse treatment
programs grew from 519 in 2000 to 793 in 2004, according to DOC records.
This mainly reflected the addition or expansion of substance abuse treatment
programs at the facilities in Shakopee, Lino Lakes, Willow River, and
Thistledew. During this period, the state’s total prison population also grew,
from 6,276 in July 2000 to 8,333 in July 2004. Overall, the growth in admissions
to treatment programs (53 percent) was somewhat greater than the growth in the
prison population (33 percent). Thus, the percentage of the state’s inmate
population that entered treatment grew from 8.3 percent in 2000 to 9.5 percent in
2004. DOC was unable to provide us with data on trends in actual expenditures
for substance abuse treatment during this period, mainly because data on these
expenditures were commingled with data on spending for other behavioral health
services. DOC staff said that the program expansions occurred partly by
increasing the number of inmates per therapist in existing treatment programs.
During the 2000-04 period, the department also increased inmates’ opportunities
to participate in aftercare in prison following completion of prison-based
treatment. The department has two such aftercare programs at the Lino Lakes
prison, and total admissions to these programs more than doubled—from 143 in
2000 to 380 in 2004.
In addition, three prisons (Lino Lakes, Faribault, and Shakopee) have had
“psycho-educational” programs that address substance abuse issues. DOC does
not consider these programs to be “treatment,” due to their short duration and
lack of individual counseling. We found that:
•

The Department of Corrections has expanded inmates’ opportunities
to participate in short-term substance abuse education programs in
recent years.

The number of admissions to DOC’s psycho-educational substance abuse
programs grew from 322 in 2000 to 898 in 2004, mainly due to the expansion of
existing programs. The percentage of the state’s inmate population that entered a
psycho-educational program grew from 5.1 percent in 2000 to 10.8 percent in
2004. Thus, there was significant growth in admissions to education programs
that addressed substance abuse, compared with the more modest growth in
admissions to the prisons’ substance abuse treatment programs.
Decisions about whether to refer inmates to treatment or psycho-educational
programs have depended partly on the amount of time inmates are scheduled to
serve in prison.13 Prison-based treatment programs typically last from 6 to 12
months, while prison-based psycho-educational programs are three months or
less. Table 5.1 shows that nearly 45 percent of all persons who entered prison in
2004 had less than six months of prison time to serve, so they would not have
had time to complete even the shortest prison-based treatment program and
would only have been eligible for prison-based psycho-educational programs.
13

DOC is in the process of making psycho-educational programming the initial stage of its prisonbased treatment programs, rather than a stand-alone type of program. Some offenders—such as
those with short times to serve in prison—would only complete the psycho-educational component
of treatment in prison, and DOC officials said they hope to help these offenders continue treatment
in the community upon release.

SUBSTANCE ABUSE TREATMENT

Table 5.1: Projected Length of Prison Time for
Persons Entering Prison, 2004
Many offenders
are not in prison
long enough to
complete a
treatment
program lasting
six months or
more.

Type of Prisoner
New Court Commitments or
Probation Violators

Supervised Release
Violators

Projected Length of
Stay in Prison

Number of Persons
Entering Prison

Less Than 6 Months
6 to 12 Months
1 to 3 Years
More Than 3 Years

1,168
1,107
1,464
740
4,479

26.1%
24.7
32.7
16.5
100.0%

Less Than 2 Months
2 to 3 Months
4 to 7 Months
8 to 12 Months
More than 1 Year

444
808
520
105
102
1,979

22.4%
40.8
26.3
5.3
5.2
100.0%

Percentage

NOTE: The length of prison stays is relevant because prison-based substance abuse treatment
programs typically require at least six months to complete. In contrast, prison-based substance
abuse education programs typically require three months or less to complete.
SOURCE: Minnesota Department of Corrections.

We examined the extent to which inmates actually participated in prison-based
treatment prior to their release. We selected random samples of inmates released
from prison in January to March 2004 whose most recent prison assessment
indicated that they were “chemically dependent.”14 Our samples were large
enough to be representative of all chemically dependent inmates released during
this period.15 We found that:
•

A large majority of chemically dependent inmates did not
participate in prison-based substance abuse treatment prior to their
release in 2004.

Overall, 75 percent of chemically dependent male inmates did not participate in
substance abuse treatment in prison. Meanwhile, 25 percent did participate,
including 17 percent who completed treatment prior to release and 8 percent who
started treatment but did not finish it. Besides inmates who participated in
treatment, another 30 percent of the chemically dependent male inmates
participated only in short-term education programs that, as noted earlier, are not
considered to be “treatment.” Altogether, 55 percent of chemically dependent
male inmates participated in prison-based treatment or education programs, while
45 percent did not participate in any sort of substance abuse program.

We did not conduct such an analysis for inmates assessed to be “chemically abusive.” Earlier,
we noted that chemically abusive inmates comprised about 25 percent of inmates assessed in 2004.
15
We examined a sample of chemically dependent male inmates and all chemically dependent
female inmates released during this period.

TREATMENT FOR PRISONERS: USE AND AVAILABILITY

Seventeen percent
of chemically
dependent
inmates
completed
treatment in
prison prior to
release.

Among chemically dependent female inmates, 71 percent did not participate in
substance abuse treatment in prison. About 29 percent enrolled in treatment,
including 17 percent who completed treatment prior to release and 12 percent
who started treatment but did not complete it. In addition, 26 percent of
chemically dependent female inmates participated only in short-term education
programs. Altogether, 55 percent of chemically dependent female inmates
participated in prison-based treatment or education programs, while 45 percent
did not participate in any sort of substance abuse program.
The Department of Corrections has limited information regarding reasons for
offenders’ non-participation in treatment. In some cases, inmates in our sample
who were assessed as chemically dependent were not recommended for treatment
by DOC’s assessment staff, perhaps due to the remaining length of their prison
sentences. In some cases, inmates who had been recommended for treatment by
assessors were not directed to treatment by the program review team. But a
majority of chemically dependent inmates were directed to treatment by the
program review teams and did not receive it. Currently, DOC’s management
information systems do not provide reliable information about reasons that
individual inmates did not receive treatment, such as inmate refusal to
participate, lack of space in treatment programs, or other reasons.16
Whatever the reasons for inmates’ non-participation in treatment, we found that:
•

Officials in most agencies that supervise released prisoners are
dissatisfied with the availability of prison-based treatment.

Of the directors of community-based corrections agencies that supervise released
inmates, 12 percent expressed satisfaction with the availability of substance
abuse treatment in prison, 69 percent expressed dissatisfaction, and the remainder
offered no opinion.17 In our view, these directors are in a reasonable position to
judge the availability of prison-based treatment, given their responsibilities to
arrange for services and supervision that offenders need following prison.
The Governor’s 2006-07 biennial budget request did not include a request for
additional substance abuse programming.18 But, in 2005, the Department of
Corrections responded to legislative questions by stating that it would need large
increases in substance abuse program capacity to “adequately” serve the state’s
inmates. Specifically, the department said that it needed a total of 2,170 beds in
prisons for inmates in primary treatment programs, well above its existing 500
beds. The department also said that it needed 400 beds for persons in psycho

We did not examine the department’s paper records for individual inmates to determine whether
these files documented reasons for non-participation in treatment.
17

Office of the Legislative Auditor survey of community-based corrections directors, September
2005. The responses shown here are for the 29 agencies (representing “Community Corrections
Act” counties and counties where offender supervision is provided by the Department of
Corrections) that supervise adult felons, excluding three agencies that responded “not applicable”
to the question.
18

The department requested $920,000 a year in state funding to continue 14 chemical dependency
positions for which federal funding was scheduled for elimination. This request was not intended
to expand substance abuse programming.

SUBSTANCE ABUSE TREATMENT
educational substance abuse programs, which is double its existing 200 beds.19
Department staff estimated that such expansions in treatment and psychoeducational programming would entail additional staffing expenditures of about
$23 million annually.20

There is a
shortage of
treatment beds in
Minnesota’s
prisons, although
the number of
beds needed
appears to be less
than DOC has
estimated.

In our view, the department should reconsider its estimate of the number of
treatment beds needed. The estimate was based on the assumption that 60
percent of 6,500 offenders entering prison annually need chemical dependency
treatment before they are released.21 However, as noted earlier, nearly 45 percent
of the persons entering prison in 2004 had less than six months of prison time to
serve, which would have made them ineligible to enter a treatment program.22 In
addition, some inmates are assessed to be neither chemically dependent nor
abusive, while others refuse to participate in programming, drop out of programs
(or are terminated from them), or have barriers to participation (such as lack of
English skills). This suggests that the department’s estimate of treatment bed
needs was too high. Although questions can be raised about the department’s
estimate, we think it is still clear that:
•

There are too few substance abuse treatment beds in Minnesota
prisons to meet the needs of inmates with chemical use problems.

We offer no recommendations on what level of additional investment in
treatment the Legislature should make, but we think that the shortage of
treatment beds represents a lost opportunity to engage offenders in the prisonbased “rehabilitative programs” required by state law.23 The 2005 Legislature
increased funding somewhat for prison-based substance abuse treatment. It
appropriated $1 million per year “for increased funding for [prison-based]
chemical dependency treatment programs,” although the department also faces
the possible loss of $920,000 per year in federally-funded chemical dependency
positions sometime during the current biennium. The 2005 Legislature also
authorized funding to expand the Challenge Incarceration Program, which has a
chemical dependency treatment component.24 In the next section, we
19

Dennis Benson, Deputy Commissioner, Department of Corrections, letter to Senator Jane
Ranum, March 21, 2005.

Patricia Orud, Minnesota Department of Corrections, e-mail to Joel Alter, Office of the
Legislative Auditor, September 8, 2005.
21

Ibid.

Of the 4,479 persons who entered prison on “new commitments” in 2004, the department
estimated that 1,168 had less than six months to serve at the time of admission. Of the 1,979
supervised release violators who returned to prison in 2004, the department estimated that 1,772
had less than seven months to serve at the time of admission. Some of these offenders could be
served by short-term education programs, but they would not have enough prison time to complete
an entire treatment program.

23
24

Minnesota Statutes 2004, 244.03.

Laws of Minnesota 2005, chapter 20, art. 1, sec. 22, subd. 4, authorized a building to
accommodate “up to 100 additional beds” at the Challenge Incarceration Program’s Willow River
site. In addition, the department is in the process of adding 12 beds to the Stillwater treatment
program (through double-bunking), creating a 24-bed program at the Moose Lake prison, and
creating a 50-bed sex offender treatment program at the Rush City prison with a chemical
dependency treatment component. Also, a private Minnesota prison used for some DOC inmates
intends to add a 25-bed chemical dependency unit during 2006.

TREATMENT FOR PRISONERS: USE AND AVAILABILITY

recommend that the department develop a plan for improving substance abuse
services for inmates, both during and after prison.

PARTICIPATION IN TREATMENT AFTER
RELEASE FROM PRISON
Previous studies have questioned whether prison-based treatment programs can
be effective without “aftercare” following an offender’s release, as we discussed
in Chapter 2. After leaving prison, offenders have more access to chemicals and
less direct supervision, and they may need ongoing support to maintain sobriety.
In Minnesota, a key element in an inmate’s transition from prison to the
community is the “release plan.” According to DOC policy, a draft release plan
must be sent by DOC to the agency that will supervise the offender after
release.25 The plan sets forth conditions with which the offender must comply,
perhaps including participation in chemical dependency services. The
supervising agent may accept or reject the draft plan, and differences of opinion
between the agent and DOC are to be resolved by DOC’s Deputy Commissioner
for Community and Juvenile Services.
We examined the release plans for more than 130 chemically dependent inmates
who were released during the first three months of 2004. We found that:
•

Prison release
plans often have
vague provisions
regarding post-
release chemical
dependency
services, and this
is a source of
concern to local
corrections
officials.

Prison release plans for inmates assessed as chemically dependent
have provided minimal direction regarding post-release substance
abuse assessment and programming.

Nearly all release plans contained a boilerplate condition of release such as:
“Comply with chemical dependency programming as directed by the
agent/designee.” Typically, the plans did not specify the type or intensity of the
programming—for example, whether the offender needed professionally-directed
treatment, participation in a support group, or some other substance abuse
services. Also, the plans did not direct supervising agents to arrange for
chemical use assessments in the community following the offender’s release.
Rather, the plans usually left complete discretion regarding assessment and
programming to the supervising agents in the community.
Although the supervising agencies have authority to reject DOC’s draft release
plans, many of the agencies expressed concern regarding the chemical
dependency components of release plans. In a statewide survey of communitybased corrections agency directors, only 31 percent said that the release plans
“always,” “almost always,” or “usually” have adequate provisions regarding the
need for chemical health services in the community, while 69 percent said that
the plans “sometimes,” “rarely,” or “never” have adequate provisions.26 In
addition, 55 percent of directors said that their agencies “sometimes,” “rarely,” or
25
Minnesota Department of Corrections Policy 203.010. The draft must be sent four months prior
to the offender’s supervised release date, if time permits.
26

Office of the Legislative Auditor survey of community-based corrections directors, September
2005. The responses reported here only include responses from directors of Community
Corrections Act agencies and Department of Corrections district offices (N=29).

SUBSTANCE ABUSE TREATMENT
“never” received adequate information from DOC on the substance abuse
services that offenders on supervised release received in prison.27
We also examined the extent to which inmates entered licensed, communitybased substance abuse treatment programs following their release from prison.28
Our review indicated that:
•

Most chemically
dependent
inmates do not
complete
treatment in
prison, yet few
enter treatment
when they leave
prison.

Among chemically dependent persons placed on supervised release
from prison in 2004, only 8 percent of the men and 10 percent of the
women entered a licensed chemical dependency treatment program
within six months of their release.

Our analysis did not consider the participation by released offenders in other
types of substance abuse services, such as support groups. For example, one of
the prison-based treatment programs—the Challenge Incarceration Program at
Willow River—encourages its “graduates” released to locations in the Twin
Cities metropolitan area to participate in a six-month, state-funded aftercare
program.29 In addition, it is likely that some prison releasees participate in
support groups such as Alcoholics Anonymous, for which we did not have
information on participation. Also, Department of Corrections officials told us
that vigorous correctional supervision is the most important aspect of post-release
“aftercare” that offenders receive.
But, while aftercare can take various forms, most directors of community-based
corrections agencies expressed concerns to us about the lack of aftercare options
for released prisoners. Only 7 percent said they were satisfied with the
availability of aftercare services in the community for offenders who completed
substance abuse treatment in prison. Sixty-nine percent of the directors
expressed dissatisfaction with aftercare, and the rest expressed no opinion.30
For some chemically dependent prisoners, it is possible that support from friends,
family, or informal groups such as Alcoholics Anonymous is sufficient to
maintain sobriety in the community. But most chemically dependent inmates do
not receive substance abuse treatment in prison. We think it would be preferable
for DOC and local corrections agencies to jointly develop specific plans for post

Ibid.

Specifically, we looked at the experience of a representative, random sample of 267 inmates who
were assessed in prison as chemically dependent and released from prison in the first three months
of 2004. As noted in the previous section, most of these inmates did not enroll in treatment during
prison. To determine whether offenders enrolled in community-based treatment programs
following their release, we searched for the offenders’ names and birthdates in data that are
regularly submitted by substance abuse treatment providers to the Department of Human Services.
Our analysis may underestimate treatment participation if treatment providers have not fully
reported treatment participation information to the Department of Human Services, as required.
29

The Challenge Incarceration Program’s aftercare consists of three months of weekly aftercare
meetings, followed by three months of monthly meetings. The aftercare program is not a licensed
treatment program. Offenders may be excused from aftercare meetings for reasons such as work or
family obligations.
30

Office of the Legislative Auditor survey of community-based corrections directors, September
2005. These responses reflect the Community Corrections Act agencies and Department of
Corrections district offices, which supervise adult felons (N=29).

TREATMENT FOR PRISONERS: USE AND AVAILABILITY

release chemical dependency services, rather than leaving these decisions entirely
to the supervising agencies.
RECOMMENDATION

DOC should work with community-based corrections agencies to develop
more specific plans for individual inmates’ post-release chemical
dependency services.
For an offender who has been in prison-based substance abuse treatment, the
prison release plan should direct the supervising agency to provide appropriate
services based on a review of DOC’s treatment program discharge summary or
pre-release chemical use assessment. DOC staff told us they intend to conduct
chemical use assessments, just prior to release, on all offenders who have
participated in prison-based treatment. They said that this could provide a basis
for determining these offenders’ needs for continuing services in the
community.31 If a county refuses to recognize the validity of a pre-release
assessment done by DOC, the release plan should require the county to arrange
for a post-release chemical use assessment, provided by the county or the
offender’s insurer.32

Prisoners’ release
plans and treat
ment discharge
summaries should
have more specific
provisions about
inmates’ service
needs following
release.

We also think DOC should be prepared to write release plans that address the
needs of chemically dependent inmates who did not participate in prison-based
treatment. DOC has not yet adopted a policy on pre-release assessments, but
department officials told us they do not intend to conduct pre-release assessments
on inmates deemed chemically dependent at prison intake who did not participate
in prison-based treatment. At a minimum, however, we think that such offenders
should be required in their release plans to obtain community-based chemical use
assessments, as arranged by the supervising agency.
We recognize that the availability of community-based substance abuse services
varies around the state, as does public funding for them. Thus, local agencies
should play a key role in identifying which services can best meet the needs of
released offenders. But, where possible, we think that offenders’ prison release
plans and prison treatment discharge summaries should have more specific
provisions about the need for post-release substance abuse assessments or
services, thus providing a stronger basis for the supervising corrections agents to
hold the offenders accountable for participation. DOC officials told us they are
in the process of implementing several initiatives to help prisoners successfully
return to the community, and we think that our recommendation is consistent
with these efforts.33
31
Most local agencies do not send staff to the prisons to conduct chemical use assessments before
an inmate is released.
32

State laws and rules do not require local “placing agencies” (counties, tribes, and prepaid health
plans that contract with DHS) to abide by assessments conducted by DOC prior to a prisoner’s
release, and some local agencies told us they do not use DOC’s assessments.
33
For example, DOC intends to hire staff in its minimum security units to help coordinate pre
release support groups and post-release continuing care. In addition, DOC is in the process of
adding chemical dependency “release and reintegration specialists” at some prisons to work with
the prisons’ case managers on inmate release planning.

SUBSTANCE ABUSE TREATMENT
RECOMMENDATION

DOC should
develop a strategy
for improving
chemically
dependent
offenders’ access
to treatment
during and after
prison.

The Department of Corrections should present the 2007 Legislature with a
plan for (1) improving the availability of substance abuse treatment and
related services in Minnesota’s prisons, and (2) helping to ensure that
chemically dependent offenders receive the treatment or related services
they need upon release from prison.
In this chapter, we noted that there has been limited participation by inmates in
chemical dependency treatment during and after prison. In our view, there is a
need for additional state funding for such treatment. First, we think there is a
need for additional treatment capacity in Minnesota prisons, although the bed
needs should be documented further by the Department of Corrections. Second,
post-release treatment (if it is provided at all) is now usually paid for by the
offender’s private insurance or the state’s Consolidated Chemical Dependency
Treatment Fund, but some released offenders do not have insurance and are not
eligible for the Consolidated Fund. To help ensure that there is follow-through
on offenders’ release plans, the Legislature may wish to appropriate some
designated chemical dependency funding that could “follow the offender” into
the community following release, particularly for higher risk offenders.
RECOMMENDATION

For offenders released from prison, the Legislature should amend state law
to require that DOC provide the supervising corrections agency with prison
records of each offender’s assessments and services for chemical use.
We think that DOC and the Legislature should help to ensure that communitybased corrections agencies receive sufficient information about the prison-based
assessments and services received by inmates who will be released to these
agencies’ supervision. Earlier in this chapter, we noted that a majority of
directors of community-based corrections agencies said they were dissatisfied
with the information they have received from DOC on offenders’ prison-based
substance abuse services. DOC officials told us they have been working to
increase the amount of treatment-related information shared with supervising
agents, but they said they would welcome statutory clarification of the
department’s obligations in this area. The 2005 Legislature amended state law to
require that, for sex offenders released from prison, DOC provide supervising
corrections agencies with information on the prison-based services these
offenders received.34 We think that the Legislature should enact similar
provisions regarding prison-based substance abuse assessments and services, for
the purpose of helping community-based agencies make appropriate decisions
regarding treatment and supervision.

Laws of Minnesota 2005, chapter 136, art. 3, sec. 3.

Treatment for Prisoners:
Outcomes
SUMMARY

A key goal of substance abuse treatment for chemically dependent
offenders is to reduce criminal behavior. Inmates who completed treatment
programs in Minnesota prisons had lower arrest and conviction rates
following release than (1) inmates who completed short-term substance
abuse education programs, and (2) inmates who started treatment but failed
to complete it. Recidivism rates were particularly low for inmates who
completed the Challenge Incarceration Program, a boot camp program
with a substance abuse treatment component. The Department of
Corrections should develop a strategy for improving the post-release
outcomes of chemically dependent inmates assigned to short-term
programs and those who do not complete treatment.

n Chapter 5, we said that too few offenders receive substance abuse treatment
in prison, and there is insufficient release planning for inmates’ post-prison
substance abuse services. However, before the Department of Corrections or
Legislature expand existing prison-based programs, it is important to consider
whether these programs are providing effective services. In this chapter, we
examine the following questions:
•

To what extent do prison inmates complete the substance abuse
programs they enter in prison?

•

What impact, if any, does completion of a prison-based substance
abuse program have on chemically dependent persons’ rates of
subsequent arrest and conviction?

•

To what extent do prisoners have chemical use relapses following
completion of a prison-based substance abuse program?

PROGRAM COMPLETION RATES
Completing a treatment program does not guarantee “success” when an inmate
leaves prison, but studies have indicated that the duration of time spent in
treatment is related to post-treatment outcomes.1 To maximize the impact of a
1

William M. Burdon, Nena P. Messina, and Michael L. Prendergast, “The California Treatment
Expansion Initiative: Aftercare Participation, Recidivism, and Predictors of Outcomes,” The
Prison Journal 84, no. 1 (March 2004): 61-80. The authors found that time spent in prison-based
treatment was a significant predictor of aftercare participation and returns to incarceration in the 12
months following release.

SUBSTANCE ABUSE TREATMENT
program, it is generally preferable for a treatment participant to complete the full
regimen, rather than quitting or being discharged early by staff. Also, it is
important to follow completion of a prison-based program with appropriate postrelease programming in the community, as recommended in Chapter 5.
The Department of Corrections (DOC) has two general types of prison-based
substance abuse programs, with differing duration and content. First, substance
abuse treatment programs generally take 6 to 12 months to complete, and they
include education, group counseling, and individual counseling components.
Second, substance abuse psycho-educational programs generally take three
months or less, are not considered “treatment,” and do not include individual
counseling. The impact of treatment depends on both the duration and nature of
services provided, but we noted in Chapter 3 that the National Institute on Drug
Abuse has suggested that programs of less than 90 days are of “limited or no
effectiveness.”2
In Chapter 5, we noted that only about 25 percent of chemically dependent
inmates released in 2004 participated in prison-based substance abuse treatment
programs prior to release, and another 30 percent participated only in substance
abuse education programs. Table 6.1 shows completion rates for the prisonbased substance abuse programs among inmates who left these programs in 2004.
Completion rates indicate the percentage of inmates who completed a program
they started.3 We found that:
•

In 2004, 66
percent of inmates
completed the
prison-based
treatment
programs they
entered.

Most inmates complete the prison-based substance abuse programs
they enter, although participants in treatment programs generally
have lower completion rates than participants in shorter education
programs.

For the treatment programs lasting 6 to 12 months, 66 percent of the inmates who
left these programs in 2004 had completed them.4 In contrast, the shorter
psycho-educational programs had a completion rate of 81 percent in 2004.
Higher completion rates do not necessarily translate into better outcomes, and we
note later in this chapter that inmates who completed the education programs had
relatively high recidivism rates compared with some other categories of
chemically dependent inmates.
Variation among individual programs’ completion rates partly reflects the types
of inmates they serve, according to DOC staff. For example, the Lino Lakes
prison has two substance abuse treatment programs that each last 9 to 12 months
but have very different completion rates. One program serves only sex offenders,
and 86 percent of persons leaving the program in 2004 completed it. Staff said
that the participants in the substance abuse program for sex offenders tended to
2

National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based
Guide (Washington, D.C., 1999), 1, 14.

Inmates who never entered a program (which happens often, as discussed in Chapter 5) are not
counted as “non-completers” in the completion rates discussed here.

4
The 66 percent completion rate includes the Challenge Incarceration Program, which has a
chemical dependency treatment component during its six-month first phase. As we note later, this
program has unique penalties for non-completion. If this program is excluded from our analysis,
the overall completion rate for treatment programs was 60 percent in 2004.

TREATMENT FOR PRISONERS: OUTCOMES

Table 6.1: Client Completion Rates for Prison-Based
Substance Abuse Programs, 2004
Total Inmates
Discharged
Treatment Programs
Challenge Incarceration (Thistledew)
Sex offender long-term CD treatment (Lino Lakes)
Challenge Incarceration (Willow River)
Sex offender medium-term CD treatment (Lino

Lakes)
Reshape medium-term (St. Cloud)
TRIAD medium-term (Lino Lakes)
Atlantis medium-term (Stillwater)
Shakopee long-term
TRIAD program for mentally ill, chemically

dependent inmates (Lino Lakes)
TRIAD long-term (Lino Lakes)
Total
Psycho-Educational Programs
Shakopee short-term
Shakopee relapse
New Dimensions (Faribault)
TRIAD (Lino Lakes)
Total

Percentage of
Discharges Due
to Program
Completion

21
28
183

95%

12
58
187
89
34

83
72

38
134
784

66%

66
49
459
320
894

91%

81%

SOURCE: Office of the Legislative Auditor’s analysis of Department of Corrections data.

be more compliant than the offenders served in the prison’s long-term “TRIAD”
treatment program, which staff described as serving the most criminal and
chemically dependent inmates. The TRIAD program had a completion rate of 40
percent in 2004.
In addition, differences in programs’ completion rates may reflect differences in
the sanctions that inmates face for failing to complete the programs. State law
authorizes the Commissioner of Corrections to impose disciplinary sanctions on
inmates who refuse to participate in rehabilitative programs.5 For most
programs, the typical penalty for failing to participate is 30 to 45 days of
additional incarceration, according to staff with DOC’s Hearings and Release
Unit.6 But inmates in DOC’s Challenge Incarceration Program have stronger
incentives than inmates in other programs to complete their program, which may
5
6

Minnesota Statutes 2004, 244.03.

Minnesota Department of Corrections, Offender Discipline Regulations (St. Paul, 2005), Policy
510, authorizes penalties of up to 360 days of additional incarceration for refusal to participate in a
program to which the inmate has been directed. Within each prison, a “program review team”
designated by the warden has authority to issue treatment directives. The department does not keep
summary data regarding how many offenders have received penalties for refusal to participate in
programs, or the length of these penalties.

100

SUBSTANCE ABUSE TREATMENT
partly account for the fact that more than 80 percent of its participants in 2004
completed the prison-based phase of the program that included chemical
dependency treatment. Inmates who successfully complete the first six-month
phase of the Challenge Incarceration Program, unlike other inmates, can be
released from prison before serving two-thirds of their sentence. In addition,
inmates who fail to complete the Challenge Incarceration Program have time
added to their term of imprisonment, equal to the time they spent in the program.7
We also analyzed changes over time in inmates’ completion of treatment
programs lasting six months or longer, including inmates in the Challenge
Incarceration Program.8 We found that:
•

DOC should aim
to increase
inmates’
compliance with
directives to
treatment.

The overall completion rates for prison-based substance abuse
treatment programs have increased in recent years.

Sixty-six percent of inmates who left prison-based treatment programs in 2004
had completed them, compared with a 48 percent completion rate among inmates
who left treatment programs in 2000.9 The improvements in completion rates are
encouraging, but we think that the Department of Corrections should continue
working to increase them. The department’s authority to direct prisoners to
treatment and sanction them for not participating provides a unique opportunity
to intervene in the lives of chemically dependent offenders. But we also
recognize that if the department gave longer periods of “extended incarceration”
to inmates who do not comply with treatment directives, this could increase the
size of the department’s prison population.10 This is an important consideration
at a time when the state’s prisons are operating at capacity.

CRIMINAL RECIDIVISM FOLLOWING
TREATMENT
One goal of substance abuse treatment is to reduce the likelihood that chemically
dependent offenders will commit new crimes following treatment, and thus
reduce the threat to public health and safety. For our study, we tracked 507 adult
offenders released from a Minnesota state prison between January and March
2002 to determine the extent to which they were arrested or convicted for a new

Besides these incentives to complete the Challenge Incarceration Program, inmates apply to
participate in the program, so they may be more amenable to treatment than inmates who are
directed by DOC to participate in treatment. In addition, Minnesota Statutes 2004, 244.17, subd. 3,
excludes from this program persons who were imprisoned for murder, manslaughter, criminal
sexual assault, kidnapping, robbery, arson, or other offenses involving death or intentional personal
injuries.

8
This analysis did not include shorter-term, psycho-educational programs, which are not
considered to be “treatment.”
9

Completion rates were 53 percent in 2001, 56 percent in 2002, and 69 percent in 2003. The 2004
program completers represented 6 percent of the state’s total July 2004 inmate population (not all
of whom are chemically dependent), while the 2000 program completers represented 4 percent of
the state’s total July 2000 inmate population.

It is also possible that stronger penalties for non-compliance would have the intended effect of
encouraging inmates to participate in treatment, with minimal need for the use of extended
incarceration.

TREATMENT FOR PRISONERS: OUTCOMES

101

offense during the three years following their release.11 The Department of
Corrections had assessed each of these prisoners as chemically dependent for at
least one substance prior to their release. We also looked at the relationship
between inmates’ recidivism rates and participation in treatment, among other
variables.12
First, we looked at overall recidivism rates for all 507 chemically dependent
prisoners in our sample. We found that:
•

Fifty-nine percent
of chemically
dependent
inmates were
rearrested within
three years of
their release.

Among Minnesota inmates deemed chemically dependent and
released from prison in early 2002, a majority were arrested for a
new offense in the three years following their release.

As shown in Figure 6.1, 59 percent of the released inmates were arrested for a
new offense in Minnesota. Also, nearly 37 percent were convicted of at least one
“serious” criminal offense—that is, one that is reported to the Minnesota Bureau
of Criminal Apprehension.13 (The bureau tracks felonies, gross misdemeanors,
and select misdemeanors.) These offenders’ new arrests and convictions were
for a mix of violent crimes (such as murder or sex offenses), property crimes,
drug crimes, and other types of crime (such as weapons offenses).14
Some of the 507 released prisoners did not have convictions for serious criminal
offenses, but they had convictions for driving-related offenses, as reported to the
Minnesota Department of Public Safety’s Driver & Vehicle Services Division.
Considering all driving offenses—including those deemed serious—we found
that 50 percent of the released prisoners were convicted for offenses ranging
11

Each of the 507 chemically dependent prisoners we tracked was released under one of the
following conditions: supervised release, Intensive Supervised Release, work release, discharged
from sentence, or released under the Challenge Incarceration Program. We looked at Department
of Corrections data on bookings into a local jail facility as a proxy for arrests, noting that all
offenders “booked” into a jail facility have been arrested, but there may be instances where persons
are arrested but not booked. We looked at convictions using data reported to the Minnesota
Department of Public Safety’s Driver & Vehicle Services Division (driving offenses), and to the
department’s Bureau of Criminal Apprehension (felonies, gross misdemeanors, and select
misdemeanors). We included only those offenses that appeared to be a new offense committed
subsequent to a prisoner’s release date, and we excluded cases coded only as a “violation of
probation.”
12

Our analysis of prisoners’ recidivism was a retrospective review of arrest and conviction data,
not a controlled study in which prisoners were randomly assigned to specific treatment programs.
Thus, we could not definitively determine treatment’s impact on recidivism. Also, we did not try to
evaluate whether the Department of Corrections assigned these prisoners to the “right” treatment
programs in prison. Some offenders participated in more than one treatment program during their
incarceration, so we could not isolate the effects of various programs on individual offender’s
recidivism.
13
The lower conviction rate does not necessarily mean that a large number of the arrested offenders
were innocent. Some were awaiting trial at the end of the three-year period, some were convicted
of lower-level offenses that did not require reporting to the bureau’s database, and others were not
prosecuted.
14
Previous research has examined overall recidivism rates of Minnesota’s released prisoners.
These rates provide some context for the rates presented in this study, even though not all released
prisoners have chemical use problems. A 1997 study by our office found that 59 percent of all
prisoners released in 1992 were rearrested and 45 percent were reconvicted of a new offense within
three years, based on Minnesota offenses only—see Office of the Legislative Auditor, Recidivism
of Adult Felons (St. Paul, January 1997), 51-52.

102

SUBSTANCE ABUSE TREATMENT

Figure 6.1: Recidivism Rates of Chemically
Dependent Prisoners Released in 2002
Within three
years of release
from prison, 36
percent of
chemically
dependent
inmates had a
new arrest or
conviction
explicitly related
to alcohol or
drugs.

Percentage of Released Prisoners
Prisoner Had New Offense of Any Type Following Release
Prisoner Had New Offense Related to Alcohol or Drugs

75%

64%
59%
50%
37%

36%

29%

Rearrest Rate -All Offenses

25%
16%

16%

Reconviction Rate -"Serious" Offenses

Reconviction Rate -Driving Offenses

Reconviction Rate -All "Serious" and
Driving Offenses
Com bined

Overall Reoffense
Rate -- Arrests and All
Convictions
Com bined

NOTE: Our sample included 507 offenders released between January 1, 2002, and March 31, 2002,
who were diagnosed by DOC as chemically dependent for at least one substance. Arrests include all
“bookings” (as a proxy for arrests) into a local jail facility. In this analysis, “serious” offenses include
felonies, gross misdemeanors, and select misdemeanors reported to the Department of Public
Safety’s Bureau of Criminal Apprehension. Driving convictions include all driving offenses reported to
the Department of Public Safety’s Driver & Vehicle Services Division. We included only those
offenses that appeared to be a new offense subsequent to a prisoner’s release date, and we
excluded cases coded only as a “violation of probation.”
SOURCE: Office of the Legislative Auditor’s analysis of data from the Department of Corrections and
the Department of Public Safety’s Bureau of Criminal Apprehension and Driver & Vehicle Services
Division.

from speeding and reckless driving to felony-level offenses such as drivingwhile-impaired and criminal vehicular operation resulting in bodily harm.15
Altogether, 64 percent of the inmates were convicted of a new offense (criminal
or driving), and 75 percent were either arrested or convicted of a new offense
within three years of their release from prison.
Figure 6.1 also shows that 29 percent of the offenders in our sample had postrelease arrests that were explicitly related to drugs or alcohol, and 25 percent had
post-release convictions for offenses (criminal or driving) that were explicitly
related to these substances. Overall, 36 percent of the inmates were either
arrested or convicted for substance-related offenses within three years of their
15
Among prisoners with a new driving conviction, 92 percent had (1) multiple new driving
convictions, (2) also been rearrested for a criminal offense, or (3) also been reconvicted of a
criminal offense reported to the Bureau of Criminal Apprehension. Driving convictions for the
remaining 8 percent were primarily for driving after withdrawal of license, failure to obey traffic
signs, speeding, and driving without insurance. Parking offenses were not included in our
calculation of recidivism rates for driving offenses.

TREATMENT FOR PRISONERS: OUTCOMES

103

release. Drugs or alcohol could have been a factor in other crimes that led to the
arrests or convictions, but this was not always apparent from the arrest and
conviction data we examined.
We then looked at the relationship between participation in prison-based
treatment programs and recidivism following release from prison. We did not
determine treatment’s impact on recidivism apart from other factors, such as
offenders’ previous treatment history and motivation to participate in treatment.
As shown in Table 6.2, we examined recidivism rates of three subgroups of our
sample of chemically dependent prisoners: (1) those who successfully completed
their assigned substance abuse program prior to release (220 prisoners), (2) those
who either quit a program prior to completion or were terminated from their
assigned program early by treatment staff for program violations (55 prisoners),
and (3) those whose treatment status was “indeterminate” (220 prisoners).16 For
the latter group, DOC computer records had no indication that the offenders
entered a prison substance abuse program, but DOC officials cautioned that these
records could be incomplete.17 The Department of Corrections determined the
length and type of programming for the prisoners based on program availability
and the prisoner’s needs and length of prison stay.
For the 220 prisoners who had completed their assigned program, we looked at
the relationship between recidivism rates and the length and type of prison-based
program they were directed to complete. First, we found that:

Treatment
completers had
lower overall
recidivism rates
than other
chemically
dependent
prisoners.

•

Prisoners who completed medium- or long-term treatment generally
had lower rates of post-release arrest and conviction than other
chemically dependent prisoners, although one-third were rearrested
or reconvicted for substance-related offenses.

As Table 6.2 shows, the chemically dependent inmates who had completed
medium- or long-term treatment in prison had a lower rearrest rate (51 percent)
than the inmates who had quit or failed programs in prison (65 percent), or
inmates whose treatment status was “indeterminate” (60 percent). They also had
a lower reconviction rate (27 percent) compared with those who quit or failed
programs (49 percent) and the “indeterminate” group (36 percent). However,
their rate of arrests or convictions for any substance-related offense (33 percent)
was similar to that of the inmates who failed programs in prison (31 percent), and
the indeterminate group (35 percent).18

We reviewed, but were unable to control for, possible differences in our subgroups of prisoners.
For example, we examined differences in the groups’ median offense severity and criminal history
score (although the reporting in the department’s information system was sometimes incomplete).
Overall, prisoners who completed substance abuse programs in prison had lower median criminal
history scores than non-completers (2.0 vs. 3.0), but completers and non-completers had the same
median offense severity level (5.0).
17
Because of incomplete reporting in the Department of Corrections prison management
information system regarding prisoners’ chemical dependency treatment, we were unable to obtain
accurate information on all 507 prisoners’ treatment histories. The department said that paper files
contain more complete information on treatment history, but even these files have incomplete
information about why prisoners did not complete their treatment directives.
18
Program completers had a higher reconviction rate for driving offenses (55 percent) than inmates
who failed programs (44 percent) and inmates with “indeterminate” treatment histories (47
percent).

104

SUBSTANCE ABUSE TREATMENT

Table 6.2: Reoffense Rates of Chemically Dependent

Prisoners Released in 2002, by Program Participation

Program Group

All Chemically Dependent

Prisoners

Percent
Rearrested

Percent
Convicted
of a New
“Serious”
Offensea

Percent
Rearrested or
Convicted for
a New Drug
or Alcohol
b
Offense

507

59%

37%

36%

220

• Medium- or Long-Term
c
Treatment

• Challenge Incarceration
Program

• Short-Term PsychoEducational Program

130

220

Prisoner Subgroups:
(1) Completed a Substance

Abuse Program

(2) Quit Program or Were

Terminated by Staff
d

(3) Indeterminate

NOTE: Our sample included 507 offenders released between January 1, 2002, and March 31, 2002,
who were diagnosed by DOC as chemically dependent for at least one substance. We included only
those offenses that appeared to be a new offense committed subsequent to but within 36 months of a
prisoner’s release date, and we excluded offenses coded only as a “violation of probation.” The
subgroup data excludes 12 prisoners who were actively participating in, but did not complete,
substance abuse programs prior to their release, as we were unable to precisely determine how
much programming they had received.
a

For purposes of this analysis, “serious” offenses are those reported to the Department of Public
Safety’s Bureau of Criminal Apprehension’s Computerized Criminal History database, and they
include felonies, gross misdemeanors, and select misdemeanors.

Includes arrest data from the Department of Corrections and conviction data from the Department of
Public Safety’s Bureau of Criminal Apprehension and Driver & Vehicle Services Division.
c

Persons who completed prison-based aftercare programs are included. Generally, aftercare
participants are inmates who have completed medium- or long-term treatment.
d

Prisoners with “Indeterminate” program status were inmates whose DOC computer records had no
indication that the offenders entered a prison-based substance abuse program. DOC officials
cautioned that some of the computer records might be incomplete.
SOURCE: Office of the Legislative Auditor’s analyses of data from the Department of Corrections,
and the Department of Public Safety’s Bureau of Criminal Apprehension and Driver & Vehicle
Services Division.

On the other hand, we found that:
•

Prisoners who completed short-term psycho-educational substance
abuse programs had recidivism rates similar to prisoners who quit
or were terminated from treatment, and they were the most likely to
have new arrests or convictions for a substance-related offense.

TREATMENT FOR PRISONERS: OUTCOMES

105

DOC officials do not consider the short-term educational programs to be
“treatment” because they do not include individual counseling components. On
all three of the recidivism measures shown in Table 6.2, prisoners who completed
short-term substance abuse programs had higher reoffense rates than prisoners
who completed longer programs. DOC staff suggested that the higher recidivism
rates for short-term educational substance abuse programs may reflect
differences in the types of inmates these programs tend to serve. For example,
DOC said that, compared with other programs, short-term educational programs
serve more inmates who have violated their supervised release or caused
discipline problems in prison.
Third, we found that:
•

Inmates who
completed the
Challenge
Incarceration
Program had
relatively low
recidivism, but it
is unclear whether
this was due to the
program or the
types of inmates it
served.

Inmates who completed the Challenge Incarceration Program (CIP)
in prison had the lowest recidivism rates compared with other
chemically dependent prisoners, including those who completed
other prison-based substance abuse programs.

As Table 6.2 shows, 26 percent of prisoners completing CIP were arrested for a
new offense in the subsequent three years, compared with 51 percent of inmates
who completed medium- or long-term treatment, 64 percent of inmates
completing short-term programs, and 65 percent who quit or were terminated
from programs. Only 4 percent of prisoners completing CIP were convicted of a
serious offense, compared with 27 percent for completers of medium- or longterm treatment, 42 percent for completers of short-term programs, and 49 percent
for those who quit or failed programs. CIP participants also had considerably
lower recidivism rates for alcohol- and drug-related offenses (17 percent) than
the full sample of 507 chemically dependent prisoners (36 percent).
As noted previously in this chapter, the Challenge Incarceration Program is
different from other prison-based treatment programs. Offenders apply to
participate in the program, rather than being directed to enter it. By statute, some
types of serious offenders are excluded from participating in this program.19
Compared with other programs, offenders in CIP potentially face stronger
incentives for completing the program and harsher sanctions for failing it.20
Perhaps the Challenge Incarceration Program simply attracts more motivated
inmates than other programs. Alternatively, perhaps the program is more
effective than other treatment programs. Our findings were based on a small
group of program completers, so the program’s recidivism over time should be
monitored by the Department of Corrections. However, it is encouraging that
graduates of this program had lower recidivism rates than other inmates on all of
our measures.

19
20

Minnesota Statutes 2004, 244.17, subd. 3.

Inmates who complete the first phase of CIP may qualify for release from prison before their
scheduled supervised release date, and inmates who fail to complete CIP have their prison time
extended by the number of days they were in CIP.

106

SUBSTANCE ABUSE TREATMENT
Finally, we looked at the relationship between recidivism rates and prisoners’
gender and age for our sample of 507 chemically dependent prisoners.21 Table
6.3 presents rearrest and reconviction rates based on these characteristics. Our
analysis showed that, among chemically dependent offenders released from
prison in early 2002, males had somewhat higher recidivism rates than females.
For example, 38 percent of chemically dependent males had a post-release arrest
or conviction for offenses explicitly related to drugs or alcohol, as did 26 percent
of females. But, among the males, 42 percent of those who completed a prisonbased substance abuse program had a post-release arrest or conviction for a drug
or alcohol offense, compared with 31 percent of the males who failed such a
program.22
In addition, we found that chemically dependent inmates under age 41 at the time
of release had higher recidivism rates than older inmates who were chemically
dependent. For example, 49 percent of released prisoners under age 21 had new
arrests or convictions related to drugs or alcohol, compared with 26 percent for
released prisoners over age 40. This is consistent with research that has shown
the declining likelihood of criminal behavior as people grow older, but it also
highlights the need for programs to effectively address younger inmates’
chemical dependency problems.23

DOC should
consider how to
improve outcomes
for chemically
dependent
offenders who
do not complete
treatment in
prison.

Overall, we do not know whether the differences in inmates’ post-release
recidivism rates reflect differences in the effectiveness of prison-based programs
rather than other factors that we could not adequately measure, such as offenders’
underlying criminality and self-motivation to change. However, the differences
in post-release recidivism between the Challenge Incarceration Program and the
short-term psycho-education programs are noteworthy. We offer no
recommendations for specific changes in the content of Minnesota’s prison-based
substance abuse programs, but we think that DOC should consider ways to better
address the treatment needs of the offenders now referred to short-term substance
abuse programs. This is important due to the short prison stays of many of these
inmates and their relatively high recidivism rates compared with other chemically
dependent inmates. Perhaps some of these offenders need more intensive
programs in prison. Also, Chapter 5 recommended improvements in DOC’s
prisoner release planning process, to help ensure that chemically dependent
offenders receive appropriate services when they leave prison.

Our sample consisted of 441 males and 66 females, ranging in age from 18 to 61, with a median
age of 30.

In Table 6.3, the program “completers” include inmates who completed either a substance abuse
treatment or substance abuse education program in prison.

As shown in Table 6.3, the inmates under age 41 who completed prison-based substance abuse
programs had lower overall rates of arrest and conviction than those who quit or were terminated
from programs. However, the program completers under age 41 had higher rates of post-release
arrest or conviction for drug or alcohol offenses than the inmates under age 41 who failed
treatment.

TREATMENT FOR PRISONERS: OUTCOMES

107

Table 6.3: Reoffense Rates of Chemically Dependent
Prisoners Released in 2002, by Gender and Age

Percent
Rearrested

Percent
Reconvicted
for a New
Serious
Offensea

Percent
Rearrested or
Convicted for a
New Drug or
Alcohol
Offense

Prisoner Group

Total

All Chemically Dependent

Prisoners

507

59%

37%

36%

Gender
All Male

441

59%

37%

38%

• Completed Substance
Abuse Program

192

• Quit a Program or
Terminated by Staff

56%

33%

26%

• Completed Substance
Abuse Program

• Quit a Program or
Terminated by Staff

All Female

Age at Time of Release
All 18-20

66%

49%

• Completed Substance
Abuse Program

• Quit a Program or
Terminated by Staff

375

62%

39%

38%

• Completed Substance
Abuse Program

166

• Quit a Program or
Terminated by Staff

All 21-40

All 41 and Older

44%

24%

26%

• Completed Substance
Abuse Program

• Quit a Program or
Terminated by Staff

Includes conviction data from the Department of Public Safety’s Driver & Vehicle Services Division
and the Bureau of Criminal Apprehension’s Computerized Criminal History database of felonies,
gross misdemeanors, and select misdemeanors.
SOURCE: Office of the Legislative Auditor’s analyses of data from the Department of Corrections
and the Department of Public Safety’s Bureau of Criminal Apprehension and Driver & Vehicle
Services Division.

108

SUBSTANCE ABUSE TREATMENT
RECOMMENDATION

The Department of Corrections should develop a strategy for improving the
post-release outcomes of (1) inmates who are directed to complete shortterm programs in prison, and (2) inmates who fail the prison-based
substance abuse programs they start.

DOC should
ensure that it has
accurate records
of inmate
participation in
substance abuse
programs.

Aside from any changes in the content of prison-based programs, DOC should
consider reassessing these offenders prior to release and, where possible, provide
clearer direction in prison release plans regarding substance abuse services these
offenders may need in the community.
We also think that the department should regularly monitor the recidivism rates
of inmates assessed as chemically dependent, including those who participate in
prison-based programs and those who do not.24 However, the department needs
better data in its main information system regarding whether inmates have
completed substance abuse programs. Also, in cases where inmates did not
complete programs as directed, the department’s information system should
clearly indicate why.
RECOMMENDATION

The Department of Corrections should:
• Periodically determine the recidivism rates of inmates assessed as
chemically dependent; and
• Improve its recordkeeping of prisoners’ participation in substance
abuse programs while incarcerated, including the reasons why inmates
do not comply with directives to participate in prison-based substance
abuse programs.

RELAPSE RATES FOLLOWING RELEASE
FROM PRISON
As we discussed previously in this chapter, relapse prevention is a critical goal of
substance abuse treatment. Rearrest and reconviction rates for drug and alcohol
offenses are useful measures of whether offenders return to using chemicals
following treatment. The extent to which individuals enter treatment following
release from prison can also be a way of measuring the extent of chemical use
relapses.

DOC officials noted that budget constraints have limited the department’s ability to conduct
research in recent years. Still, DOC has periodically examined offender recidivism, and we think
that DOC could occasionally focus some of its attention on key subgroups (such as chemically
dependent offenders) as part of these ongoing efforts.

TREATMENT FOR PRISONERS: OUTCOMES

109

We tracked rates of entry into community-based treatment for 220 inmates who
had completed a substance abuse program in prison prior to their release in early
2002. Using data collected by the Department of Human Services, we identified
the offenders’ admissions to community-based treatment within the three years
following their release from prison.25 We recognize that admission to
community-based treatment or aftercare immediately following release from
prison may be a good way for offenders to reinforce the lessons they gained from
treatment in prison. Some offenders may have been directed into communitybased treatment as part of their release plan. Thus, our analysis did not count as
“relapses” any instances in which offenders entered community-based treatment
within two months of leaving prison.26 However, if offenders had been out of
prison at least two months before entering treatment, we assumed that subsequent
treatment admissions probably indicated some return to chemical use.
With these conditions in mind, we found that:
•

The relapse rates
of persons who
completed
substance abuse
programs in
prison were
similar to those of
persons who
completed
treatment in the
community.

Nearly one-fourth of all chemically dependent inmates who had
completed substance abuse programs while incarcerated were
readmitted to community-based treatment within three years of
their release.

About 23 percent of the prisoners were subsequently admitted for one or more
episodes of care in the community, as shown in Table 6.4. Relapse rates for
those prisoners who had post-release arrests or convictions (25 percent) were
slightly higher than relapse rates for prisoners who did not (18 percent).
To provide a benchmark for the relapse rates of the persons who completed
prison-based substance abuse programs, we also examined relapse rates for a
sample of individuals from the general population who had completed treatment
in the community.27 Overall, we found that chemically dependent prisoners who
completed prison-based substance abuse programs were admitted into
community-based treatment at a rate that was similar to that of individuals who
had completed treatment in the community.28

25
Our analysis may underreport readmissions to treatment. First, we did not determine
readmissions to prison-based treatment for offenders that were reincarcerated within three years of
their release. Second, offenders sometimes use aliases that would make it difficult to track
subsequent treatment placements. Finally, treatment providers might not always report treatment
episodes to the Department of Human Services.
26

Also, if offenders started a community-based program within two months of leaving prison, and
then entered another treatment program within 30 days of their discharge from the first program,
we did not count either admission as a relapse.
27

We randomly selected 350 individuals who had successfully completed community-based
treatment between January and March 2002 and tracked their readmissions to treatment over a
three-year period.
28
We estimated that 18 percent of individuals treated in the community were readmitted for care at
least once within the subsequent three years, with a margin of error (or “confidence interval”) of 5
percentage points. This relapse rate was not statistically different from the 23 percent rate we
found for released prisoners.

110

SUBSTANCE ABUSE TREATMENT

Table 6.4: Relapse Rates of Prisoners and Others
Who Completed Substance Abuse Programs in 2002
Percentage of Individuals With Reported

New Episodes of Community-Based

Treatment Within Three Years
Treatment Group
Total
All Released Prisoners Who
Completed Prison-Based
Substance Abuse Programs

Number of Relapse Episodes
0
1
2
3 or more

220

77%

18%

• Prisoner Was Rearrested or

Reconvictedb

165

• Prisoner Was Not Rearrested or

Reconvicted

350

Individuals Who Completed
Community-Based Treatment

NOTE: Our sample included 220 offenders released between January 1, 2002, and March 31, 2002,
who were diagnosed by DOC as chemically dependent for at least one substance and had completed
substance abuse programs prior to their release. We included new episodes of care that occurred
within 36 months of release. We included only those offenses that appeared to be a new offense
committed subsequent to a prisoner’s release date, and we excluded offenses coded only as a
“violation of probation.” For comparison purposes, we selected a sample of 350 individuals who had
completed community-based treatment between January and March 2002. This sample may have
included individuals previously convicted of criminal offenses.
a

Based on data reported by treatment providers to the Department of Human Services.

Based on conviction data from the Department of Public Safety’s Driver & Vehicle Services Division
and the Bureau of Criminal Apprehension’s Computerized Criminal History database of felonies,
gross misdemeanors, and select misdemeanors.
SOURCE: Office of the Legislative Auditor’s analyses of data from the departments of Public Safety,
Corrections, and Human Services.

List of Recommendations

The Legislature should:
• Amend state law to clarify responsibility for chemical use assessments of
persons jailed outside their home counties (p. 52);
• Amend state law to require that chemical use assessors interview the current
probation officer when assessing a person on probation (p. 52);
• Consider amending state law to prohibit Rule 25 assessors from having
financial conflicts of interest with treatment providers, except in
circumstances that are now specified in state rules (p. 53); and
• Amend state law to require that DOC provide the supervising corrections
agency with prison records of each released offender’s assessments and
services for chemical use (p. 96).

The Department of Human Services should:
• Distribute information to chemical health assessors on “best practices” in
assessments, including model instruments for adults and adolescents (p. 50);
• Monitor the compliance of local agencies with assessment and referral rules
(p. 50);
• Develop a directory that identifies key characteristics of each licensed chemical
dependency treatment program (p. 51)
• Present the 2007 Legislature with a plan for improving the availability of
community-based substance abuse treatment in Minnesota (p. 68);
• Report to the 2007 Legislature on the merits of changing the statutory
“maintenance of effort” provisions of the Consolidated Chemical Dependency
Treatment Fund (p. 69);
• Work with the Department of Health to develop guidelines and training materials
for health care organizations on the use of “brief interventions” for alcohol abuse
(p. 69);
• Provide local agencies with examples of “best practices” for addressing the needs
of persons being considered for “repeat” placements into publicly-funded
treatment (p. 80);

112

SUBSTANCE ABUSE TREATMENT
• Identify “best practices” to help local agencies monitor the progress of the clients
they place in treatment (p. 82);
• Periodically provide these agencies with statewide information on treatment
outcomes (p. 82); and
• Post copies of state licensing reviews and treatment program peer reviews at an
online location where they could be reviewed by agencies that make client
placements (p. 84).

The Department of Corrections should:
• Periodically obtain external reviews of the assessment procedures it uses to
determine inmates’ needs for chemical dependency services (p. 87);
• Work with community-based corrections agencies to develop more specific plans
for individual inmates’ post-release chemical dependency services (p. 95);
• Present the 2007 Legislature with a plan for (1) improving the availability of
substance abuse treatment and related services in Minnesota’s prisons, and (2)
helping to ensure that chemically dependent offenders receive the treatment or
related services they need upon release from prison (p. 96);
• Develop a strategy for improving the post-release outcomes of (1) inmates who
are directed to complete short-term programs in prison, and (2) inmates who fail
the prison-based substance abuse programs they start (p. 108);
• Periodically determine the recidivism rates of inmates assessed as chemically
dependent (p. 108); and
• Improve its recordkeeping of prisoners’ participation in substance abuse
programs while incarcerated, including the reasons why inmates do not comply
with directives to participate in prison-based substance abuse programs (p. 108).

February 7, 2006

James R. Nobles
Legislative Auditor
Office of the Legislative Auditor
Centennial Office Building
658 Cedar Street
St. Paul, MN 55155
Dear Mr. Nobles:
Thank you for the opportunity to review and respond to your office’s evaluation of substance abuse
treatment and the activities and performance of State and local agencies. The Department of Human
Services (DHS) supports the key recommendations of the report. These recommendations are consistent
with our current goals and objectives, and the development and implementation of some of these
changes is already underway.
As you are aware, DHS is in the process of implementing new requirements that will individualize
treatment for each client, replacing the current program-centered approach. When the process is
completed, these requirements will ensure that assessment and treatment planning follow best practice
methods based on the American Society of Addiction Medicine’s guidelines. These changes will
strengthen statewide assessment, referral and treatment practices, and lay a foundation for other
improvements to the chemical dependency treatment system.
There are two recommendations in the report on which we would like to comment:
• We agree with the recommendation that DHS should strengthen its oversight of county
assessment practices to address the variation in utilization of publicly-funded substance abuse
treatment. However, we would like to reinforce that conclusions about access to treatment in
any single county under the Consolidated Chemical Dependency Treatment Fund (CCDTF)
cannot be drawn simply by measuring placement activity. Needs assessment and problem event
data show that chemical use problems are not evenly distributed among counties. In addition,
chemical use problems and treatment need vary from county to county based on population
demographics such as ethnicity, co-occurring disorders and age. For example, the county noted
in the report as having the least CCDTF placement activity per adult in poverty is also the lowest
ranked county in the State for DWI arrests, drug arrests, and detoxification program admissions.

PO Box 64998 ● St. Paul, MN ● 55164-0998 ● An Equal Opportunity Employer

James R. Nobles
Page 2
February 7, 2006
Conversely, the county with the highest placement rate also had the highest detoxification
admission and DWI incident rate in the State, and the largest percentage of American Indian
population (an ethnicity demonstrated to have higher treatment need). The primary reason for
variance in CCDTF placement rates appears to be variation in need. Still there continues to be
variances in county placement practices that cannot be explained by demographics and other
factors that warrant further evaluation.
• We agree with the recommendation that the Department should provide counties with more
information about treatment program outcomes including information regarding licensing
citations. We have concerns with the recommendation that peer review information should be
made available to the public. The purpose of peer review is quality assessment of the program
by other members of the chemical health treatment community. Unlike licensing, peer review is
not conducted on all programs, is voluntary on the part of the program, and has no due process
component should the program believe that the reviewers are in error. The department plans to
pursue other ways for providing counties with information about treatment program outcomes.
Thank you for the work of your office in conducting this evaluation and addressing important issues
regarding the effectiveness and availability of substance abuse treatment.
Yours sincerely,

Kevin Goodno
Commissioner

PO Box 64998 ● St. Paul, MN ● 55164-0998 ● An Equal Opportunity Employer

OFFICE OF THE COMMISSIONER

Contributing to a Safer Minnesota

February 8, 2006
Honorable James R. Nobles
Legislative Auditor
658 Cedar Street Room 140
Saint Paul, MN 55155-1603
Dear Mr. Nobles:
Thank you for the opportunity to review the Legislative Auditor’s evaluation of Substance Abuse
Treatment programs in Minnesota. In our judgment, the Report represents a concise survey of
our state’s treatment infrastructure, a good summary of the current challenges and important
recommendations for reform. The Report is a very useful document.
As a survey of the current challenges:
•

The Report correctly notes that too little is known about why some offenders fail
to succeed in treatment and how these failures might be linked to later recidivism.
(See, Final Report at 98 - 110).
So as to discover some of the missing data, DOC has initiated an evaluation
project for the Chemical Dependency Treatment Program. Likewise, among the
next steps in the Department’s reentry initiative – known as the Minnesota
Comprehensive Offender Reentry Plan, or MCORP – are assessments and case
planning for each offender, and “electronic case plans” that will enable better
tracking of outcomes.

•

The Report confirms the importance of obtaining external reviews of the
Department’s assessment procedures. (See, Final Report at 87).
A key part of the collaboration between DOC and the Department of Human
Services is the regular reviews of DOC’s Chemical Dependency services –
including DOC’s assessment practices. Moreover, on a quarterly basis, external
stakeholders on the Behavioral Health Advisory Committee review the
Department’s treatment methods, policies and procedures.

www.doc.state.mn.us

1450 Energy Park Drive, Suite 200 St. Paul, Minnesota 55108 PH 651.642.0282 FAX 651.642.0414 TTY 651.643.3589

EQUAL OPPORTUNITY EMPLOYER

As an outline for possible reform:
•

The Report corroborates our view that the pace of improvements, innovation and
coverage of our treatment practice is bounded only by the availability of
resources. (See, Final Report at 96). The Department of Corrections has already
undertaken a number of pioneering improvements to its substance abuse treatment
practice, and will do more as additional resources are available.

•

The Report rightly concludes that a stronger continuum of services would prevent
relapses. (See, Final Report at 108). To build this broader continuum of services,
DOC has implemented the MCORP project and, to the extent that resources are
available, hopes to increase the number of Rule 25 chemical dependency
assessments that are completed on offenders. With greater collaboration among
agencies, and improved access to the Consolidated Treatment Fund, we believe
that better outcomes are within reach.

•

The Report correctly states that in order to strengthen the continuum of treatment
services, DOC needs to fortify its collaborations with community-based agencies.
(See, Final Report at 95). The DOC is strengthening these relationships through
its advisory committees and a statewide commitment to offender reentry. These
early successes point the way for future work.

In summary, the Department of Corrections shares your commitment to improving outcomes
from the state’s investment in substance abuse treatment, and regards this Report as a vital tool
for educating everyone on these important issues.
We look forward to working with your office, the Minnesota Legislature and other stakeholders
in developing a set of treatment strategies that will lead the nation in their efficacy and value.
Very truly yours,

Joan Fabian
Commissioner of Corrections

Recent Program Evaluations
Forthcoming Evaluations
Pesticide Regulation, February 2006
Tax Compliance, February 2006
Liquor Regulation, March 2006
Public Assistance Eligibility Determination for
Non-Citizens, Spring 2006
Agriculture
Animal Feedlot Regulation, January 1999

Government Operations
Professional/Technical Contracting, January 2003
State Employee Health Insurance, February 2002
State Archaeologist, April 2001
State Employee Compensation, February 2000
State Mandates on Local Governments, January 2000
Fire Services: A Best Practices Review, April 1999
State Building Code, January 1999
9-1-1- Dispatching: A Best Practices Review, March 1998
State Building Maintenance, February 1998

Criminal Justice
Substance Abuse Treatment, February 2006
Community Supervision of Sex Offenders, January 2005
CriMNet, March 2004
Chronic Offenders, February 2001
District Courts, January 2001

Health
Nursing Home Inspections, February 2005
Minnesota Care, January 2003
Insurance for Behavioral Health Care, February 2001

Education, K-12 and Preschool
School District Integration Revenue, November 2005
No Child Left Behind, February/March 2004
Charter School Financial Accountability, June 2003
Teacher Recruitment and Retention: Summary of
Major Studies, March 2002
Early Childhood Education Programs, January 2001
School District Finances, February 2000
Minnesota State High School League, June 1998
Remedial Education, January 1998

Human Services
Substance Abuse Treatment, February 2006
Child Support Enforcement, February 2006
Child Care Reimbursement Rates, January 2005
Medicaid Home and Community-Based Waiver Services for
Persons with Mental Retardation or Related Conditions,
February 2004
Controlling Improper Payments in the Medicaid Assistance
Program, August 2003
Economic Status of Welfare Recipients, January 2002
Juvenile Out-of-Home Placement, January 1999
Child Protective Services, January 1998

Education, Postsecondary
Compensation at the University of Minnesota,
February 2004
Higher Education Tuition Reciprocity, September 2003
The MnSCU Merger, August 2000
Environment and Natural Resources
State-Funded Trails for Motorized Recreation,
January 2003
Water Quality: Permitting and Compliance Monitoring,
January 2002
Minnesota Pollution Control Agency Funding,
January 2002
Recycling and Waste Reduction, January 2002
State Park Management, January 2000
Counties’ Use of Administrative Penalties for Solid and
Hazardous Waste Violations, February 1999
Metropolitan Mosquito Control District, January 1999
School Trust Land, March 1998
Financial Institutions, Insurance, and Regulated Industries
Energy Conservation Improvement Program, January 2005
Directory of Regulated Occupations in Minnesota,
February 1999
Occupational Regulation, February 1999

Housing and Local Government
Preserving Housing: A Best Practices Review, April 2003
Managing Local Government Computer Systems: A Best
Practices Review, April 2002
Local E-Government: A Best Practices Review, April 2002
Affordable Housing, January 2001
Preventive Maintenance for Local Government Buildings:
A Best Practices Review, April 2000
Jobs, Training, and Labor
Workforce Development Services, February 2005
Financing Unemployment Insurance, January 2002
Miscellaneous
Gambling Regulation and Oversight, January 2005
Minnesota State Lottery, February 2004
Transportation
Metropolitan Airports Commission, January 2003
Transit Services, February 1998

Evaluation reports can be obtained free of charge from the Legislative Auditor’s Office, Program Evaluation Division,
Room 140 Centennial Building, 658 Cedar Street, Saint Paul, Minnesota 55155, 651/296-4708. Full text versions of recent
reports are also available at the OLA website: http://www.auditor.leg.state.mn.us