Characteristics of Clients Who Left Outpatient Treatment During the First 30 Days

In Brief
In 2007, 13.7 percent of non-intensive outpatient discharges dropped out of substance abuse treatment or had their treatment terminated by the facility during the first 30 days of treatment Short-stay discharges were less likely than long-stay discharges to be employed (31.6 vs. 43.4 percent) and more likely to be unemployed (37.6 vs. 27.8 percent) Short-stay discharges were less likely than long-stay discharges to have been referred to treatment by the criminal justice system (41.3 vs. 60.0 percent) and more likely to have been self-referred (26.4 vs. 16.3 percent)

The goal of substance abuse treatment is to achieve positive outcomes, including a reduction in or elimination of substance use and improvements in social functioning and overall well-being.¹ Treatment completion and length of stay in treatment are important predictors of positive treatment outcomes. While research shows that adequate lengths of stay in substance abuse treatment are critical for achieving positive treatment outcomes,²^,³ many clients fail to complete their entire course of treatment. Clients who drop out of treatment early are at an increased risk of relapse. Identifying the differences and similarities between clients who stay in treatment at least 90 days and those who drop out of treatment early may help treatment providers to develop strategies that will increase the likelihood of treatment completion among those clients who are at risk of leaving treatment prematurely.

This report draws upon data from the Treatment Episode Data Set (TEDS) to compare the characteristics of two groups of clients—those who dropped out of treatment or had their treatment terminated by the facility within 30 days of admission and those who stayed in treatment for at least 90 days.⁴ Specifically, this report focuses on discharges from non-intensive outpatient treatment (hereafter referred to as "outpatient treatment"), which is the most common type of substance abuse treatment service.

In 2007, there were approximately 730,200 outpatient discharges aged 12 or older. Of these, 13.7 percent (approximately 100,000) dropped out or had their treatment terminated by the facility during the first 30 days of treatment (hereafter referred to as "short-stay discharges"); 44.5 percent (approximately 324,750) stayed in outpatient treatment for 90 days or longer (hereafter referred to as "long-stay discharges").⁵

The average age at admission and the proportions of male and female admissions were similar for both short-stay and long-stay discharges. The average age at admission was 32.9 years among short-stay discharges and 32.6 years among long-stay discharges. Males represented 66.4 percent of the short-stay discharges and 68.5 percent of the long-stay discharges. The majority of both groups were non-Hispanic White. Non-Hispanic Blacks comprised the second largest proportion of both groups. Short-stay discharges were less likely than long-stay discharges to be non-Hispanic White (55.1 vs. 59.2 percent) and more likely to be non-Hispanic Black (24.7 vs. 18.1 percent) (Figure 1).

Short-stay discharges were less likely than long-stay discharges to be employed (31.6 vs. 43.4 percent) and more likely to be unemployed (37.6 vs. 27.8 percent).⁶ Similar proportions of both groups graduated from high school or received their GED (42.4 and 44.0 percent) or received some education after high school (20.8 and 23.8 percent). However, short-stay discharges were slightly more likely than long-stay discharges to have less than a high school education (36.7 vs. 32.2 percent).⁷

Figure 1. Race/Ethnicity among Short-stay and Long-stay Discharges from Regular Outpatient Substance Abuse Treatment: 2007

* Alaska did not report TEDS data for 2007. Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

Figure 1 Table. Race/Ethnicity among Short-stay and Long-stay Discharges from Regular Outpatient Substance Abuse Treatment: 2007
Race/Ethnicity	Short-stay Discharges	Long-stay Discharges
White, Non-Hispanic	55.1%	59.2%
Black, Non-Hispanic	24.7%	18.1%
Hispanic	14.6%	16.3%
American Indian/Alaska Native*	1.8%	2.2%
Asian/Pacific Islander	1.0%	1.6%
Other	2.7%	2.6%
*Alaska did not report TEDS data for 2007. Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

The three primary substances of abuse most commonly reported among short-stay discharges were alcohol, marijuana, and cocaine. These discharges were less likely than long-stay discharges to report primary alcohol abuse (35.7 vs. 41.9 percent) and more likely to report primary cocaine abuse (15.8 vs. 10.9 percent) or primary opiate abuse (11.5 vs. 6.6 percent) (Figure 2). Both groups were about equally likely to report primary marijuana abuse (23.2 and 24.0 percent) or primary abuse of methamphetamine (11.0 and 12.2 percent).

The majority of short-stay discharges reported multiple substances of abuse at admission (61.5 percent); 16.8 percent reported alcohol abuse only, and 21.7 percent reported a single drug of abuse.⁸ In comparison, 56.2 percent of long-stay discharges reported multiple substances of abuse at admission, 24.2 percent reported alcohol abuse only, and 19.6 percent reported a single drug of abuse.

Figure 2. Primary Substance of Abuse among Short-stay and Long-stay Discharges from Regular Outpatient Substance Abuse Treatment: 2007

Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

Figure 2 Table. Primary Substance of Abuse among Short-stay and Long-stay Discharges from Regular Outpatient Substance Abuse Treatment: 2007
Primary Substance of Abuse	Short-stay Discharges	Long-stay Discharges
Alcohol	35.7%	41.9%
Marijuana	23.2%	24.0%
Cocaine	15.8%	10.9%
Opiates	11.5%	6.6%
Methamphetamine	11.0%	12.2%
Other	2.8%	4.5%
Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

Among short-stay discharges, the most common sources of referral to treatment were the criminal justice system and self-referrals. Short-stay discharges were less likely than long-stay discharges to have been referred to treatment by the criminal justice system (41.3 vs. 60.0 percent) and more likely to have been self-referred (26.4 vs. 16.3 percent) (Figure 3).

Figure 3. Principal Source of Referral among Short-stay and Long-stay Discharges from Regular Outpatient Substance Abuse Treatment: 2007

Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

Figure 3 Table. Principal Source of Referral among Short-stay and Long-stay Discharges from Regular Outpatient Substance Abuse Treatment: 2007
Principal Source of Referral	Short-stay Discharges	Long-stay Discharges
Criminal Justice System	41.3%	60.0%
Individual/Self-referral	26.4%	16.3%
Community Organizations	14.2%	11.0%
Other Health Care Provider	8.2%	3.9%
Alcohol/Drug Abuse Care Provider	7.7%	6.0%
Other	2.3%	2.8%
Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

Among short-stay discharges, 63.1 percent had no health insurance coverage, and 18.9 percent had Medicaid (Table 1).⁹ Similarly, 59.8 percent of long-stay discharges had no health insurance and 16.1 percent were covered by Medicaid. Short-stay discharges were less likely than long-stay discharges to have private health insurance (10.1 vs. 15.9 percent).

Government payments other than Medicaid or Medicare were the expected primary source of payment for more than two fifths (43.8 percent) of short-stay discharges and one third (36.0 percent) of long-stay discharges.¹⁰ Approximately one quarter of both short-stay (25.7 percent) and long-stay discharges (26.2 percent) were self-pay clients. Short-stay discharges were less likely than long-stay discharges to report no charge for their treatment (8.6 vs. 14.8 percent).

Table 1. Percent Distribution of Regular Outpatient Substance Abuse Treatment Short-stay and Long-stay Discharges, by Health Insurance and Expected/Actual Primary Source of Payment: 2007
Health Insurance and Source of Payment	Short-stay Discharges	Long-stay Discharges
Total	100.0%	100.0%
No Health Insurance	63.1%	59.8%
Medicaid	18.9%	16.1%
Private Insurance	10.1%	15.9%
Other Insurance	8.0%	8.1%

Government Payments Other than Medicaid/Medicare	43.8%	36.0%
Self-Pay	25.7%	26.2%
Medicaid Payments	10.2%	12.6%
Other Payment Source	11.7%	10.3%
No Charge	8.6%	14.8%
Note: Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2007.

TEDS data indicate that 1 of every 2 outpatient discharges remain in treatment fewer than 90 days, and about 1 in 7 drop out of treatment or have their treatment terminated by the facility within the first 30 days. By leaving treatment too soon, individuals with substance abuse problems are less likely to achieve and maintain a stable recovery. Early treatment termination also has financial implications for treatment facilities because of the considerable resources already invested in client assessment, intake, and counseling. Thus, identification of clients who are at risk for leaving treatment prematurely has potential benefits for both clients and treatment providers.

The findings presented in this report point to several client characteristics that were associated with adequate length of stay in outpatient treatment. Specifically, long-stay discharges were more likely than short-stay discharges to report alcohol as their primary substance of abuse and less likely to report cocaine or opiates. Long-stay discharges were also more likely to have been referred to treatment by the criminal justice system and to be employed. These findings suggest that employment and the criminal justice system may provide external incentives that motivate individuals to complete their treatment regimen. For example, individuals referred to treatment by the criminal justice system may be more motivated than other individuals to remain in treatment to fulfill their legal obligations and to avoid (re)incarceration. Similarly, individuals who are employed may be motivated to complete treatment to maintain their employment.

Conversely, individuals who are unemployed or who have no legal requirement to complete treatment may lack external incentives that motivate them to remain in treatment. This underscores the importance of a comprehensive client assessment process that evaluates those aspects of the client's life that are likely to support or impede participation in treatment. After identifying the factors that facilitate or prevent client participation in treatment, providers can develop a treatment plan that includes ancillary and supportive services, such as employment counseling and training, social skills development, and assistance with obtaining social services that will help increase client participation in treatment. Providing clients with these necessary resources and services may increase the likelihood that clients will remain in treatment and build a foundation for recovery.

¹ McKay, J. R., & Weiss, R. V. (2001). A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups: Preliminary results and methodological issues. Evaluation Review, 25, 113-161.
² Gossop, M., Marsden, J., Stewart, D., & Rolfe, A. (1999). Treatment retention and 1 year outcomes for residential programmes in England. Drug and Alcohol Dependence, 57(2), 89-98.
³ Gossop et al. determined that the "critical treatment threshold" was 90 days or more for long-term residential treatment programs and 28 days or more for inpatient or short-term stay residential programs.
⁴ Clients may be terminated from a treatment program by a facility for a variety of reasons, such as refusing to follow the prescribed treatment program, failing to follow facility rules and procedures, or exhibiting violent behavior.
⁵ For 2007, 46 States and jurisdictions reported discharge data, including AR, AZ, CA, CO, CT, DC, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, and WY. However, AR reported no discharges from regular outpatient treatment.
⁶ Employment status is evaluated only for discharges 16 years or older.
⁷ Education is evaluated only for discharges 18 years or older.
⁸ The denominator in the calculation of reports of multiple substance use, alcohol abuse only, or single drug of abuse excluded discharges that did not report at least one substance of abuse at admission.
⁹ Health insurance is a Supplemental Data Set item. It was reported for at least 75 percent of all admissions aged 12 or older by 28 of the 45 States and jurisdictions reporting discharges from regular outpatient treatment in 2007—AZ, CO, DE, HI, ID, IL, IN, KS, KY, LA, MA, MD, ME, MS, MT, ND, NE, NH, NJ, NV, OK, OR, PR, SC, SD, TX, UT, and WY. These 28 States and jurisdictions accounted for 39.2 percent of the total discharge records that could be linked to an admission or transfer record in 2007.
¹⁰ Expected/actual primary source of payment is a Supplemental Data Set item. It was reported for at least 75 percent of all admissions aged 12 or older by 22 of the 45 States and jurisdictions reporting discharges from regular outpatient treatment in 2007—CO, DE, HI, IA, ID, KS, KY, LA, MO, MS, ND, NH, NJ, NV, OH, PR, RI, SC, SD, TX, UT, and VT. These 22 States and jurisdictions accounted for 28.7 percent of the total discharge records that could be linked to an admission or transfer record in 2007.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 5, 2011). The TEDS Report: Characteristics of Clients Who Left Outpatient Treatment During the First 30 Days. Rockville, MD.