Alcohol abuse is positively associated with incarceration and is the most common substance abuse problem among offenders. However, most prisons and jails do not offer alcohol treatment and only 10% of offenders who need treatment receive it. Among those who do receive treatment, alcohol-related problems following release and recidivism are drastically reduced. Guided by the Socio-Cultural Framework for Health Services Disparities, this dissertation sought to describe past and future trends of treatment utilization in correctional settings, as well as identify predictors of treatment completion among offenders with alcohol as their primary substance of abuse. Racial/ethnic disparities have been identified repeatedly throughout the criminal justice system (CJS) and include the underrepresentation of racial/ethnic minorities in treatment in prisons and jails. Therefore, racial/ethnic disparities were a primary focus of this research.
Study 1 used the Treatment Episode Dataset – Admissions (1992-2014) to compare racial/ethnic differences in treatment utilized in a correctional setting (versus non-correctional settings) among treatment-seekers with alcohol as their primary substance of abuse (n=5,565,884). A higher within-group proportion of African Americans (2.4%) received treatment in a prison or jail, versus 1.2% of Whites and 1.1% of Hispanics. Using forecasted estimates from a generalized linear model (2015-2025), African American men had significantly higher odds of utilizing treatment in a correctional setting in 2025, compared to White men (adjusted odds ratio [aOR] = 1.52, 95% confidence interval [95% CI] = 1.45-1.60). No significant difference between Hispanics and Whites was identified.
Study 2 used the Treatment Episode Dataset – Discharges (TEDS-D) (2006-2014) to model treatment completion with individual and system-level factors among offenders with alcohol as their primary substance of abuse (n=23,655). African Americans had 29% lower odds of treatment completion compared to Whites (aOR = 0.71, 95% CI = 0.65-0.76). African Americans and Hispanics referred to treatment by the CJS demonstrated lower odds of treatment completion, compared to Whites also referred by the CJS (aOR = 0.63, 95% CI = 0.57-0.70; and aOR = 0.85, 95% CI = 0.74-0.98, respectively). African Americans and Hispanics referred by the CJS demonstrated even lower odds of treatment completion, compared to Whites referred by any non-CJS source (aOR = 0.50, 95% CI = 0.41, 0.61; aOR = 0.74, 95% CI = 0.57-0.97, respectively).
Study 3 used a reduced TEDS-D dataset (2013-2014) to investigate state-level characteristics and treatment completion (n=3,798). Whites and Hispanics were largely unaffected by state-level factors. Among African Americans, those in states where the level of alcohol consumption was high (versus low) and in states which spent a higher percent of their budget on corrections (versus lower) were less likely to complete treatment (aOR = 0.11, 95% CI = 0.02-0.55; and aOR = 0.24, 95% CI = 0.08-0.75, respectively). African Americans in states where the incarceration disparity was high between Hispanics and Whites (versus low) and in states with a high percentage of Republican legislators (versus low) were more likely to complete treatment (aOR = 4.39, 95% CI = 1.10, 17.50; and aOR = 3.88, 95% CI = 1.21, 12.44, respectively).
African Americans experienced disparities in treatment services utilization and completion on multiple ecological levels. Few differences between Hispanics and Whites were identified throughout all three studies. A comprehensive outlook of future trends in treatment utilization in correctional settings provides needed perspective on the scope and size of the challenge ahead. Better understanding predictors of treatment completion among offenders may inform interventions aimed at reforming the CJS, improving correctional health services, and promoting evidence-based state legislative priorities.