Substance Use, Treatment Need and Receipt of Treatment in Minnesota:

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1 Substance Use, Treatment Need and Receipt of Treatment in Minnesota: Results from Minnesota Student Survey, Minnesota Survey on Adult Substance Use, and Drug and Alcohol Abuse Normative Evaluation System By Eunkyung Park, Ph.D. Performance Measurement and Quality Improvement December 2006 This report is posted on DHS web site:

2 Acknowledgments Most of all, I would like to thank all the students who participated in Minnesota Student Survey and their parents who allowed them to take part in the survey. I also should thank those adult Minnesotans who voluntarily participated in the statewide telephone survey. Without their willingness to open up and share their private part of lives, this report would have not been possible. Special recognition goes to school coordinators of the student survey, the group of researchers at the University of Minnesota who conducted the statewide adult survey and the treatment center staff who diligently reported information about each treatment episode. Finally, I d like to acknowledge several of my colleagues who provided valuable resources to this project. Carl Haerle prepared 2004 DAANES data for this report and Judy Palermo at MN Center for Health Statistics provided me with census data for the state. Vicki Kunerth reviewed the earlier version of this report and Judy Ekern helped me with final editing and layouts. Also, I would like thank all of my colleagues at DHS as well as those from other state agencies who came to my presentation and provided valuable comments. 2

3 Table of Contents Page Executive Summary... 4 I. Introduction II. Substance Use. 10 Alcohol. 10 Tobacco. 12 Marijuana.. 15 Other illicit drugs.. 16 III. Treatment Need for Substance Use Disorder.. 17 IV. Receipt of Treatment for Substance Use Disorder.. 22 V. Gap Between Treatment Need and Treatment Receipt VI. Characteristics of Minnesotans Receiving Treatment VII. Summary and Concluding Remarks

4 Executive Summary Minnesota has long been regarded as a leader in the treatment of chemical dependency. Policy makers and various treatment advocates have worked diligently to ensure that treatment services are accessible for people who need them. As part of this on-going effort for effective prevention and treatment planning, the Minnesota Department of Human Services periodically collects data from Minnesota residents, both adolescents (MSS) and adults (MNSASU), on their substance use and treatment need as well as from all patients who enter treatment in Minnesota (DAANES). This report summarizes major findings from these three data sets. The following are some of the main findings for each section in this report: Any alcohol drinking in past 30 days: Adults between the ages of 25 to 44 had the highest proportion of drinkers. There was no significant gender difference among youths, but more male adults reported it than female adults. Among younger students (6 th and 9 th graders), American Indians had the highest proportion of drinkers, but among 12 th graders and throughout adulthood, whites reported the highest proportion of drinkers. Heavy alcohol drinking (drinking 5 or more drinks per occasion): There was a bigger and more consistent gender difference with more males than females reporting heavy alcohol use. There was no significant difference between the young adults under the legal drinking age and those between the ages of 21 to 24. American Indians had the highest proportion of heavy drinkers across all age categories except high school seniors who had white students reporting a higher proportion of heavy drinkers than AI. The heavy drinking behavior among middle aged and older Hispanics did not decrease as much as in the white or AI counterparts. Any cigarette smoking in past 30 days: There was not much difference between genders across all age groups. Overall, young adults between the ages of 18 and 24 reported the highest proportion of smokers, but among American Indians and blacks, the 25 through 44 year olds reported the highest proportion of smokers. Smoking is most prevalent among AI across all age groups. Heavy cigarette smoking (smoking half pack or more a day): Fewer female students reported heavy smoking than their male counterparts, but no significant gender difference was found among adults. Among whites, the young adults had the highest proportion of heavy smokers. The rate then decreased for the rest of adulthood, but this declining pattern was not shown by any of the minority groups. 4

5 American Indians had the highest proportion of heavy smokers and the proportion kept increasing across all age categories. Marijuana use past year: Marijuana use was high among the older adolescents and young adults with fewer females than males reporting it. American Indians had the highest proportion of users across all age groups. After young adulthood, marijuana use sharply declined in all racial/ethnic groups except blacks who did not show a decline between the young adult and mid-adult periods. Other illicit drug use during the past year: In general, more males than females reported using other illicit drugs during the past year except 9 th graders who showed more female students using them. American Indians, in general, marked the highest proportion of users except 12 th graders, of which Hispanics showed the highest proportion of users. Use of other illicit drugs declined after the young adult period among all racial/ethnic groups, but among black Minnesotans, the use rate remained steady between mid adulthood (25-44) and older adulthood (45 or older). Treatment need: Consistent with the overall patterns of substance use, treatment need is higher among high school seniors and young adults than the other age groups: 7.4% of 9 th graders, 17.6% of 12 th graders, 21.8% of young adults, 10.4% of the year olds, 7. of year olds and 1.3% of the seniors were in need of treatment for substance abuse disorders. Across all age groups, more males than females were in need of treatment, except 9 th graders, of which 7.6% female and 7.3% male students were in need of treatment. American Indians had the highest proportion in need of treatment followed by whites across all age groups, except 9 th graders, of which Hispanics were second after AI students. Treatment need peaked among young adults for American Indians and whites, and among 12 th graders for Hispanics and Asian Pacific Islanders, then it started to decline. Blacks, however, did not show a similar declining pattern among middle aged and older adults. Among Minnesota adults, treatment need for an alcohol problem was higher than treatment need for a drug problem in each racial/ethnic group, except American Indians who showed no significant difference. For both alcohol and drug problems, adult males showed significantly higher treatment need than female counterparts (12.1% vs. 4.7% for alcohol; 3.3% vs. 1.6% for drug). For alcohol problems, both American Indian and white adults showed significantly higher treatment need compared to other minority groups. For drug problems, American Indian adults showed significantly higher treatment need compared to both whites and other minority groups. 5

6 The vast majority (9) of white adults in need of treatment had alcohol problems whereas the vast majority (81%) of American Indians in need of treatment had problems with illicit drugs. Compared to white adults in need of treatment, American Indians in need of treatment are about 4 times more likely to have drug problems only, and about 3 times more likely to have both alcohol and drug problems. Receipt of treatment: In 2004, 33,553 Minnesota residents (0.7% of the total state population) entered treatment programs, of which 69% were male. Compared to the general population in the state, males, young and middle aged adults (18 through 44 year olds), American Indians and blacks were disproportionately represented in the treatment population. Among American Indians and whites, a higher percentage of the late teens and young adults entered a treatment program than other age groups, whereas among blacks, adults between the ages of 25 and 64 showed the higher percentage. Gap between treatment need and treatment receipt: Across all age categories, only a small proportion of those in need of treatment actually received treatment in 2004 (between 4% among the 14 year olds and 13% among the 17 year olds). The gender distribution among adults in treatment closely reflected the gender distribution among adults in need of treatment. Among youth, however, females were under-represented in the treatment population relative to their needs. The gap between treatment need and treatment receipt was the biggest among white Minnesotans with only about 7% of whites in need receiving treatment, whereas 32% of American Indians in need and 39% of blacks in need received treatment in Minnesota adults with a drug problem were more likely to receive treatment than those with an alcohol problem. However, American Indian adults who had an alcohol problem received treatment at a higher rate compared to those with a drug problem. Characteristics of those receiving treatment Compared to Minnesota adults who were in need of treatment, those who received treatment were more likely to be single, less educated, and not working. Two-thirds of Minnesotans who admitted to treatment in 2004 had been in treatment previously. American Indians had the highest proportion of treatment repeaters with 78% having at least one previous treatment, followed by blacks (74%) and whites (66%). Alcohol was the primary substance of abuse for 51% of patients, marijuana for 21%, methamphetamine for 12% and crack/cocaine for 9%. Primary substance of abuse varies by age of patients. Citation of marijuana as their primary substance decreased with age from 7 of youth patients to 4% of seniors in treatment mentioning it, whereas citation of alcohol increased with age 6

7 from 15% of youths to 86% of seniors. Crack/cocaine was cited mostly by adults between the ages of 25 to 64. For whites, American Indians and Hispanics, alcohol was the primary substance of abuse for more than half of patients. Among black patients, crack/cocaine was the most cited primary substance of abuse closely followed by alcohol and marijuana. Two- thirds (66.8%) of patients completed treatment satisfactorily, and 23.9% left treatment against staff advice or were discharged due to noncompliance with program requirements. Blacks and American Indians had the lowest rate of completion. 7

8 I. Introduction Substance abuse and dependence cause a tremendous burden on individuals and society, including impaired personal relationships, mental and physical health problems, and the resulting costs of health care and law enforcement. Policy makers and various treatment advocates in Minnesota have worked diligently to ensure that treatment services are accessible for people who need them. As part of this on-going effort for effective prevention and treatment planning, the Minnesota Department of Human Services periodically collects information on people s alcohol and drug use. This report describes the extent of alcohol, tobacco, and illicit drug use among people in Minnesota, estimates need of treatment for substance use disorders, and examines the gap between the treatment need and actual receipt of treatment using the information collected from three separate data sets. Data Sources and Major Variables Data sets used for this report include Minnesota Student Survey (MSS), Minnesota Survey on Adult Substance Use (MNSASU), and Drug and Alcohol Abuse Normative Evaluation System (DAANES). The Minnesota Student Survey (MSS) is a statewide school-based survey conducted every three years among public school students in 6 th, 9 th and 12 th grades. MSS is not a sample based survey, but a census inviting all the students in public schools to participate voluntarily. This report used the 2004 MSS data which were collected in the spring of 2004 from 48,131 6 th graders, 49,210 9 th graders and 34, th graders from 301 school districts. The overall participation rate was 66%. Those who were 18 or older in the 2004 MSS data are excluded from the analyses, resulting in the final count of 108,144 youths in the data set. Information on substance use and need for treatment among adults in Minnesota is from MNSASU, a statewide survey of Minnesota adults on their substance use. A stratified random sample design was employed and a total of 16,891 telephone interviews were completed between October 2004 and July 2005 in English (16,340 interviews) and in Spanish (551 interviews). The overall response rate was 55%. All the percentages reported from the MNSASU are weighted percentages to compensate for the unequal probability of being selected in the sample due to the complex sampling procedure. Treatment data both on youths and adults are from the DAANES, which gathers reports of all treatment episodes from treatment facilities in the state. DAANES show that there were 42, 846 treatment episodes during the year of Some people entered a treatment program more than once in a year. Including only the first episode when there was more than one episode for a person within the year, the final DAANES data set used for this report consisted of 33,553 treatment episodes (3,652 youths and 29,901 adults; 68.9% males). 8

9 Throughout the report, the information was presented across subgroups based on gender, age, and race/ethnicity. Information for youths is reported for each of the three grades surveyed in MSS. Adults are subdivided by four age groups: 18-24, 25-44, and 65 or older. The age comparisons shown in this report are of different people surveyed at a certain time, rather than the same people followed over time as they grew older. The following table shows gender distribution for each age category for MSS and MNSASU. Overall, gender is distributed evenly except among 12 th graders and 65 year olds or older adults who had a bit higher proportion of females. Gender and Age Distribution for Each Data Set N Male Female MSS 6 th 47, % 49.7% 9 th 48, % 51.3% 12 th 11, % 57.7% Total 108, % 51.2% MNSASU , % 49.3% , % 51.5% , % 49.2% 65 or older 3, % 55.3% Total 16, % 51.1% Note. For MNSASU, frequencies are unweighted numbers and percentages are weighted to compensate for the unequal probability of being selected due to the complex sampling procedure. The comparison across race/ethnicity was conducted with 5 categories: American Indian, Asian/Pacific Islander (API), black, Hispanic and white. In creating the combined categories of race and ethnicity, ethnicity superseded race. That is, if one is Hispanic, s/he is categorized as Hispanic in the combined categories regardless of his/her race. The vast majorities were whites in both data sets, but the proportions of minorities were higher among youth than among adults. Race/Ethnicity Distribution for Each Data Set White American Indian Black Hispanic API mixed race/ other MSS 78.9% 1.8% 4.9% 4.9% 5.2% 4.3% MNSASU 89.3% 0.9% 3.3% 2.8% % 9

10 II. Substance Use Alcohol The proportion of Minnesota youths who reported drinking any amount of alcohol in the past month increased sharply across the three grades surveyed in MSS. By 12 th grade, 46% of male students and 45% of female students reported alcohol consumption in the past month. A relatively high proportion of youths reporting alcohol consumption is of particular concern because early alcohol use is strongly associated with the development of abuse and/or dependence later in life Any alcohol consumption in past 30 days 6 4 male female 2 6th 9th 12th This escalating pattern continued well into adulthood until the proportion of drinkers reached the highest point (73% for males; 6 for females) for the age group. The proportion of drinkers then started to decrease for the older age groups. The overall trend was similar both for males and females. While there was not much difference in past month alcohol use between male and female youths, a significant gender difference was found among adults with more males than females reporting alcohol consumption in each age group. Among 6 th graders, 9.7% of American Indian students and 9.4% of Hispanic students reported drinking, followed by black students (6.6%), whites (4.2%) and Asian/Pacific Islanders (4.1%). In 9 th grade, white students marked the third highest proportion of drinkers after American Indians and Hispanics, and in 12 th grade, they had the highest proportion of drinkers closely followed by American Indian students (47.4% and 45.9% respectively). Throughout adulthood, white Minnesotans had the highest proportion of drinkers 1. 1 Throughout the analyses, two oldest groups (45 through 64 and 65 or older) are combined for race/ethnicity comparison because the sub-sample size became too small for some minority groups. 10

11 Any alcohol consumption in past 30 days th 9th 12th American Indian Black Hispanic API White The current United States legal drinking age is 21. This might have some influence on the drinking behaviors among young adults (18-24 age group). When we divide the young adult group into two sub-groups at the legal drinking age, those who were younger than 21 reported drinking at a significantly lower rate than those who were years old (39.7% vs. 65.6%, p<.05). This is the same across all racial/ethnic sub-groups except the blacks who did not show any significant difference in drinking between the two age groups (18.2% vs. 17., p>.05). 5 Drinking 5 or more drinks per occasion male female 6th 9th 12th The gender gap is bigger and more consistent in heavy drinking behavior which is defined as drinking 5 or more drinks per occasion. There were more male heavy drinkers than females across all age groups. Less than 1% of 6 th graders reported heavy drinking, but the proportion sharply increased throughout their high school period. Among high school seniors, 36% of male students and 2 of female students reported heavy 11

12 drinking behavior. This raises even more concern since high school seniors are under the legal drinking age. The legal drinking age did not have an effect on the heavy drinking behavior as it did for any alcohol consumption among the young adult age group: There was no significant difference found between the year olds and the year olds in the proportion of heavy drinkers (26.4% vs. 23.2%). 5 4 Drinking 5 or more drinks per occasion th 9th 12th American Indian Black Hispanic API White American Indians showed the highest proportion of heavy drinkers across all age categories except among high school seniors who put the whites on the top. For both American Indians and whites, young adults between the ages of 18 and 24 reported the highest rates of heavy drinking (28.1% of whites, 37.5% of American Indians). Asian/Pacific Islanders and blacks showed relatively low proportions of heavy drinkers. The heavy drinking behavior among middle aged and older Hispanics did not decrease as much as in the white or American Indian counterparts. The proportion of 45 or older Hispanics who reported heavy drinking was very close to the rate among American Indians for the same age group (11.3% for Hispanics, 11.7% for AI). Tobacco The proportion of Minnesotans who reported any cigarette smoking in the past month sharply increased throughout the three grades of youth and it reached the highest percentage point among young adults for both genders. Unlike the other substance use behaviors where we usually find higher use among males than females, there was not much difference between genders in cigarette smoking. In 9 th and 12 th grades, there were more female than male students reporting any cigarette smoking in past 30 days although the difference was small. 12

13 Any cigarette smoking in past 30 days male female 6th 9th 12th Smoking is most prevalent among American Indians throughout the age categories. Among the young, more American Indians reported smoking than their white counterparts, but among young adults between the ages of 18 and 24, the difference became insignificant (47% for AI, 43% for white). Throughout the rest of adulthood, the gap between American Indians and whites became significant again. Among American Indians and blacks, the smoking rate kept increasing well into mid adulthood reaching its highest point among the year olds. For the other racial/ethnic groups, the highest proportion of smokers was found among the young adults, and then the rate started decreasing. Any cigarette smoking in past 30 days th 9th 12th American Indian Black Hispanic API White Heavy cigarette smoking (smoking a half pack or more a day) showed a pattern similar to any cigarette smoking in the past month with the highest proportion of heavy smokers found among young adults for both males and females. Although fewer female students reported heavy smoking behavior than their male counterparts, the difference was not as large as in heavy drinking behavior and none of the differences among adults was found 13

14 statistically significant. The declining of proportions of heavy smokers among middle aged and older adults was not as big as in heavy drinking behavior Smoking half pack or more cigarettes a day 2 1 6th 9th 12th male female American Indians again showed the highest proportion of heavy smokers throughout the age categories. Among whites, the young adults marked the highest proportion of heavy smokers, and the rate decreased for the rest of adulthood. However, this declining pattern was not shown by any of the minority groups. Especially among American Indians, the proportion of heavy smokers kept increasing across all 6 age categories. The differences between American Indians and the rest of the racial/ethnic groups became significant in the mid adulthood and older age groups. 5 4 Smoking half pack or more cigarettes a day th 9th 12th American Indian Black Hispanic API White 14

15 Marijuana Marijuana use was high among older adolescents and young adults, with the peak period of use occurring in the 12 th grade (29.6% for male; 25.3% for female). The use of marijuana decreased a little among young adults and continued decreasing throughout the adulthood with very little reporting use among mid to older adults. Gender difference in use started appearing in 12 th grade with fewer females than male students reporting use, and this pattern continued into adulthood until use leveled off among seniors. Among adult age categories, the two middle aged groups (25-44 and 45-64) showed statistically significant gender difference. 5 4 Any marijuana use in past 12 months 3 2 male female 1 6th 9th 12th Among 6 th graders, 8.4% of American Indian students and 7% of Hispanic students reported using marijuana during the past year, followed by 3.8% of black students, and just over 1% of white and Asian/Pacific Islander students. Marijuana use increased sharply among 9 th graders with use reported by 40.8% of American Indians, 27.7% of Hispanics, 19.1% blacks, 15.5% whites and 11.4% APIs. 5 4 Any marijuana use in past 12 months th 9th 12th American Indian Black Hispanic API White 15

16 Throughout the age categories, marijuana use was most prevalent among American Indians. Among the young, it was Hispanic students who marked the second highest proportion of users, but the proportion of users among Hispanics sharply declined among young adults whereas the comparable decline did not occur among the American Indian and white counterparts who ranked respectively first and second in their proportion of users. Marijuana use sharply declined after young adulthood in all racial/ethnic groups except blacks who showed 10.9% of the young adult and 11.2% of 25 through 44 year olds reporting its use. Other illicit drugs Other illicit drugs include cocaine, hallucinogens, stimulants, depressants, narcotics, inhalants, and others prescription drugs. Sixth graders were asked only about the last two classes of drugs. Similar to marijuana use, although with less prevalence, other illicit drugs are used mostly by young people with very few older adults reporting use in the past 12 months. Although, more males than females reported using illicit drugs in each adult age category, none of the differences found statistically significant. Among 9 th graders, more female than male students reported use (13.7% vs. 11.2% respectively). 5 4 Any other illicit drug use in past 12 months 3 2 male female 1 6th 9th 12th American Indians, in general, showed the highest proportion of users of other illicit drugs except among 12 th graders. The use rate in 12 th grade among American Indians decreased while it remained steady among other racial/ethnic groups pushing Hispanic students to the top closely followed by American Indians. This might have resulted from a combination of the generally high dropout rates among substance users and relatively small American Indian sample size, especially among 12 th graders. 16

17 Use of other illicit drugs declined after the young adult period among all racial/ethnic groups, but the proportion of black users remained steady between mid adulthood (25-44 year olds) and the 45 or older age group. 5 Any other illicit drug use in past 12 months th 9th 12th American Indian Black Hispanic API White III. Treatment Need for Substance Use Disorder Treatment need is indicated for substance abuse and dependence, which are determined based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition (DSM-IV) (American Psychiatric Association, 2000). A diagnosis of dependence requires meeting three or more of the seven criteria that include symptoms such as tolerance, withdrawal, use in larger amount than intended, a great deal of time spent to use a substance or to recover from its effects, failed attempts to control substance use, continued use despite physical/emotional problems, and important social, occupational or recreational activities given up due to substance use. A diagnosis of substance abuse requires meeting at least one of the four criteria in the absence of a dependence diagnosis: continued use despite recurrent social or interpersonal problems; recurrent use in physically hazardous situations; recurrent substance related legal problems; recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home. The questions measuring treatment need were not asked of 6 th graders. Overall, 7.4% of 9 th graders, 17.6% of 12 th graders, 21.8% of young adults, 10.4% of the year olds, 7. of year olds and 1.3% of the seniors were found in need of treatment for substance abuse disorders. Consistent with the overall patterns of substance use, treatment need is higher among high school seniors and young adults than the other age groups. Across all age groups, more males than females were found in need of treatment except 9 th graders of which 7.6% female and 7.3% male students were in need of treatment. Treatment need among 17

18 12 th graders was higher among males than females, and it further increased among males to mark the highest need among young adults. The need among females remained steady between high school seniors and young adults. After the young adult period, treatment need started decreasing for both genders. 4 Treatment need for substance use disorder th 12th male female A racial/ethnic comparison shows that American Indians had the highest proportion in need of treatment, followed by whites in all age groups except 9 th graders. Among 9 th graders, 22% of American Indians were in need of treatment. Hispanic students were second highest with 12.4%, followed by whites (6.9%), blacks (6.2%) and Asian/Pacific Islanders (4.9%). 4 Treatment need for substance use disorder th 12th American Indian Black Hispanic API White For both whites and American Indians, treatment need was peaked among young adults aged 18 to 24. For Hispanics and Asian/Pacific Islanders, however, the highest treatment need was shown by high school seniors, and it declined throughout adulthood. For blacks, need for treatment did not go down among older adults as seen in other racial/ethnic 18

19 groups, rather it fluctuated across age categories between 5% and 11% showing the symptoms for treatment need. Data from MNSASU, but not MSS, provide separate estimates of treatment need for alcohol and drugs. Among Minnesota adults, 8.3% were in need of alcohol abuse treatment whereas 2.4% were in need of drug abuse treatment. 3 Treatment need for alcohol use disorder male female 3 Treatment need for drug use disorder male female Adult males showed significantly higher treatment need both for alcohol and drug problems than female counterparts (12.1% vs. 4.7% for alcohol; 3.3% vs. 1.6% for drug). This gender gap in treatment need for alcohol problems is more consistent across age categories than for drug problems. Compared to female, male adults showed significantly higher rates of treatment need for alcohol problems across all age categories. On the other hand, the gender gap in treatment need for drug problems was significant only among young adults aged Treatment need for drug problems among the older adults is very small: For both genders, about 2% for the year olds and fewer than 1% for the 45 or older Minnesotans were in need of drug treatment. 19

20 For alcohol problems, both American Indian and white adults showed significantly higher treatment need compared to other racial/ethnic group 2, but the difference between American Indian and white adults was not significant. For drug problems, on the other hand, American Indians had a significantly higher proportion in need of treatment than either white or other group of Minnesota adults. Within each racial/ethnic group, treatment need for alcohol problems was higher than treatment need for drug problem except among American Indians. For American Indian adults, the difference in treatment need between alcohol and drug problems shown in the chart was not statistically significant. Treatment need for alcohol vs. drug across race/ethnicity 11.3% 8.6% 16.6% American Indian White Black/Hispanic/API 4.7% 2.3% 2.2% alcohol drug The following two charts show more clearly that the treatment need for alcohol problems among white and American Indian adults in Minnesota are very close. Across all adult age categories, treatment need for alcohol problems among whites was not significantly different from the need among American Indians. Both whites and American Indian young adults reported significantly higher treatment need for alcohol problems compared to their counterparts in other group. Treatment need for drug problems, on the other hand, was significantly higher among American Indian adults compared to both whites and other group across all adult age categories. 2 Examination of treatment need separately for alcohol and drug could not be done for each racial/ethnic sub-group because rare occurrence of problems combined with small sub-sample sizes resulted in some empty cells in cross tab analyses. Thus, whenever we examine the treatment need for alcohol and drugs separately across racial/ethnic groups, black, API and Hispanics were combined into other category. 20

21 4 3 2 Treatment need for alcohol use disorder by race/ethnicity across age American Indian White Other(Black/Hispanic/API) Treatment need for drug use disorder by race/ethnicity across age American Indian White Other(Black/Hispanic/API) American Indians who showed the highest need for treatment were further compared to whites in the following two charts. The overall treatment need among American Indian adults is more than double the proportion of white adults in need of treatment (20.4% vs. 9.6% respectively) 3. More than three quarters of white adults who were in need of treatment had problems with alcohol but not with drugs, whereas less than 2 of American Indian adults in need of treatment had problems with alcohol but not with drugs. The vast majority of American Indian adults in need of treatment had problems with illicit drugs (81% having either drug problem only or a combination of drug and alcohol problems). Compared to white adults in need of treatment, American Indians in need of treatment are about 4 times more likely to have drug problems only, and about 3 times more likely to have both alcohol and drug problems. 3 About 7.4% of Hispanic, 7.1% black, and 4. API adults were estimated in need of treatment for substance abuse in Minnesota. 21

22 Treatment need among White adults Did not need treatment 90.4% 9.6% Needed treatment for: alcohol only 7.4% 1.2% 1. alcohol & drug drug only Treatment need among American Indian adults drug only Did not need treatment 79.6% 20.4% Needed treatment for: alcohol & drug 7.5% 3.8% 9.1% alcohol only IV. Receipt of Treatment for Substance Use Disorder In 2004, 33,553 Minnesota residents (about 0.7% of the total state population 4 ) entered chemical dependency treatment programs 5. Their age ranged between 9 and 101 with an average age of 33. The majority of the patients (68.9%) were male. About 74% of the patients were white, 12% were black and 7% were American Indians. In the table below, the demographic characteristics are compared between those who received treatment in 2004 (treatment population) and the general population in Minnesota (state population). Males were overly represented in the treatment population: While about half of the state population was male, they represented more than two thirds 4 The US Census Bureau estimated Minnesota population for the year of 2004 as 5,096, There was a total of 42,846 treatment episodes in The number of episodes is higher due to transfers from one treatment setting to another and readmissions to treatment. For individuals with multiple admissions in 2004, only the first admission was included in the analyses. 22

23 of the treatment population. Almost half of the treatment patients were adults between the ages of 25 and 44 although this age group represented less than a third of state population. Young adults between the ages of 18 and 24 are the most disproportionately represented in the treatment population with their proportion among treatment population (20.9%) being more than double the proportion among the state population (10.4%). Demographic Comparison of the Treatment Population to the State Population Gender Age Race/Ethnicity Treatment Population State Population Male 68.9% 49.6% Under % 24.3% % 10.4% % 28.8% % 24.4% % 12.1% White 74.3% 86.7% American Indian 7.4% 1.1% Black 12.1% 4. Hispanic % Asian/Pacific Islander 0.7% 3.4% Although the majority of the treatment population in 2004 was white, they were under represented in treatment relative to their proportions in the general population in Minnesota. American Indians and blacks, however, were over-represented in the treatment population: American Indians constituted 7.4% of the treatment population but only 1.1% of the state population, and blacks constituted 12.1% of the treatment population compared with 4% of the state population. Race/Ethnicity Distribution of Adults and Youths in Treatment vs. State Population Race/Ethnicity Treatment Population Adults Youths (9-17) State Treatment Population Population State Population White 74.6% 88.9% 71.4% 81.7% American Indian 6.9% % 1.5% Black 12.8% 3.5% 6.1% 5.6% Hispanic 3.7% 2.9% 5.8% 4.4% Asian/Pacific Islander 0.6% % 23

24 Examination of the racial/ethnic distribution separately for adults and youths revealed an interesting pattern for blacks. Black adults constituted 12.8% of the adults in treatment, but only 3.5% of the state population, whereas the black youth proportion in the treatment population was not much higher than their share among the general population. American Indian, black and white patients represented about 94% of the treatment population in The following chart compared those three racial groups in their treatment utilization rates across age categories. Across all age groups, a larger proportion of American Indians than white or black Minnesotans entered treatment programs in Overall, about 5.4% of American Indians, 2.4% of blacks, and 0.6% of white Minnesotans received treatment during Treatment utilization rates among American Indians from mid-adolescence to mid-life showed an even bigger gap from the white and black counterparts. Between the ages of 14 and 44, about 8 for every 100 American Indians entered into a treatment program in 2004 compared to 1 for every 100 white counterparts and 3 for every 100 black counterparts. 14% Chemical Dependency Treatment Utilization 12% 1 8% American Indian Black White 6% 4% 2% Three racial groups showed different patterns of treatment admission across ages. The highest utilization rates were shown in mid to late teens among American Indians and whites (at ages 15 and 16 for AI; at age 17 for whites), but in mid adulthood among black Minnesotans (25-44 age group). The utilization rates among blacks were very close to the ones among whites up until the young adult period. Black Minnesotans showed an interesting rate hike among the year olds, distancing themselves from their white counterpart in their utilization rate. The proportion of black Minnesotans who entered treatment remained steady among the year olds while it declined among their 24

25 American Indian counterpart, virtually eliminating the gap in treatment utilization rates between them (2.9% among blacks and 3.2% among AI). V. Gap Between Treatment Need and Treatment Receipt Since treatment need varies across gender, age and racial/ethnic groups, treatment utilization rates should be examined in the context of treatment need. This section compares the treatment need and treatment receipt across gender, age and major race/ethnicity sub groups. Since the data about need of treatment among youth are available only for 9 th and 12 th graders, they were compared to the 14 and 17 year olds in treatment respectively. Gender distribution of those in treatment vs. in need 29.1% 30.7% 52.3% 32.9% female male 70.9% 69.3% 47.7% 67.1% in need in treatment in need in treatment adult 9th & 12th graders First, the gender distribution among those who were in need of treatment and those who received a treatment was compared. The gender distribution among adults in treatment closely reflected the gender distribution among adults in need of treatment. Among youth, however, females were under-represented in the treatment population relative to their needs: Among the 9 th and 12 th graders, just over half (52.3%) of those in need of treatment were females, but only about one third of those in treatment were females. The next chart compares treatment need and treatment receipt for each age category. Across all age categories, only a small proportion of those in need of treatment actually received treatment in 2004 (between 4% among the 14 year olds in need of treatment and 13% among the 17 year olds in need of treatment). Although the treatment need among young adults between the ages of 18 and 24 was very close to the treatment need among the 17 year olds (18.5% and 17.6% respectively), only about 8% of the young adults in need, compared to 13% of the 17 year old counterparts, actually received treatment. 25

26 Treatment Need vs. Treatment Receipt in need in treatment 1 9th/14 12th/ The following three charts compare the treatment need and the treatment receipt separately for whites, American Indians and black Minnesotans across age categories. Overall, about 7% of white Minnesotans who were in need of treatment received treatment in 2004 whereas about 32% of American Indians in need and 39% of blacks in need received treatment 6. The gap between treatment need and treatment receipt was the biggest among white Minnesotans: their treatment need ranged between 5% among the 45 or older group and 26% among young adults, but only about 0.2% up to 2% of each age group received treatment. Treatment utilization rates among whites in need of treatment ranged between 3% for the 14 year olds and 11% for the 17 year olds. Among American Indians in need of treatment, they ranged between 17% for the14 year olds and 48% for the year olds, and among blacks, they were between 5% for the 14 year olds and 52% for the 45 or older. Among whites and American Indians, treatment utilization rates among those in need of treatment were relatively higher among the 17 year olds (10.6% for whites; 44.1% for AI) and the year olds (8.6% for whites; 47.5% for AI). On the other hand, among black Minnesotans, treatment utilization rates increased with age: Among blacks in need of treatment, 5% of 14 year olds, 21% of 17 year olds, 32% of young adults, 4 of year olds, and 51% of 45 or older received treatment in These are based on the estimates for treatment need among 9 th and 12 th graders and applying them to the 14 and 17 year olds in general population estimates. 26

27 4 3 Treatment Need vs. Treatment Receipt among White Minnesotans in need in treatment 2 1 9th/14 12th/ Treatment Need vs. Treatment Receipt among American Indian Minnesotans 3 in need in treatment 2 1 9th/14 12th/ Treatment Need vs. Treatment Receipt among Black Minnesotans 3 2 in need in treatment 1 9th/14 12th/

28 The treatment need among adults was estimated separately for alcohol and drugs as described in the previous section. Here, the alcohol and drug problems are examined among the treatment population in comparison to their distribution among those in need of treatment. Problem Type among Minnesota Adults in Need of Treatment vs. Those in Treatment Alcohol Only Drug Only Alcohol & Drug White American Indian Black/Hispanic/API in need in treatment in need in treatment in need in treatment 76.6% 38.3% 18.6% 32.2% 64.1% 19.8% 10.5% 20.9% 44.5% 14.2% 23.8% 30.1% 12.9% 40.8% 36.8% 53.6% 12.1% 50. Overall, Minnesota adults with either a drug problem only or both drug and alcohol problems tend to enter a treatment program more than those with only an alcohol problem. Among white adults, for example, about 11% of those in need of treatment had a drug only problem compared to 21% of those in treatment. Those who had both alcohol and drug problems were even more likely to be in treatment: About 13% of white adults in need of treatment, compared to 41% of those in treatment, had both alcohol and drug problems. On the other hand, more than three quarters of white adults in need of treatment, compared to 38% of those in treatment, had an alcohol only problem. A similar pattern was found among the combined group of blacks, Hispanics and Asian/Pacific Islanders. The exception to this general pattern was found among American Indian adults. The American Indian adults with only an alcohol problem or both alcohol and drug problems were more likely to be in a treatment program than those with only a drug problem: 45% of those in need of treatment, compared to 14% of those in treatment, had a drug only problem, whereas 19% of those in need vs. 32% of those in treatment had an alcohol problem only and 37% of those in need vs.54% of those in treatment had both alcohol and drug problems. VI. Characteristics of Minnesotans Receiving Treatment This section examines, in more detail, those Minnesotans who received chemical dependency treatment during the year Compared to Minnesota adults who were in need of treatment, those who received treatment were more likely to be single, less educated, and not working. More than half 28

29 of Minnesota adults who entered treatment in 2004 had never married and 21.9% were divorced or separated. Just under a quarter of those in treatment in 2004 did not have a high school diploma and only 7.6% had a college degree or higher education (compared to 9% and 26% respectively of those in need of treatment). About 41% of those in treatment were laid off or otherwise unemployed with an additional 13.8% categorizing themselves as not in the labor force (homemakers, students, retirees, or disabled) compared to about 11% among those in need of treatment being either unemployed or not in the labor force. Socio-Economic Characteristics of Minnesota Adults in Treatment vs. in Need Adults in treatment Adults in need Marital Status Never married 54.8% 38.5% Married/cohabitating 22.1% 51.7% Divorced/separated 21.9% 8.4% widowed 1.1% 1.3% Education Less than high school 24.1% 9. High school graduate 56.1% 28.1% Some college 12.2% 36.7% College graduate or above 7.6% 26.1% Working Status Full time 32.1% 67.4% Part time/seasonal % Unemployed 40.5% 4.8% Not in labor force 13.8% 6.5% About one-quarter of adults (25.3%) were living with minor children when they entered treatment. About 43% of youth lived in two-parent households, 45.4% lived with a single parent, and most of the remainder lived with foster parents or other relatives. Two-thirds of Minnesotans who admitted to a treatment program in 2004 had been in treatment previously. Only one-third of those in treatment were new to treatment whereas about 43% had been in treatment once or twice, and almost a quarter had been in treatment three or more times before they entered a treatment program in Across all racial/ethnic groups, more than half of those who entered a treatment program in 2004 were repeaters. American Indians had highest proportion of treatment repeaters with 78.1% having at least one previous treatment, followed by blacks (73.8%) and whites (65.9%). 29

30 Previous treatment 5+ times 9.3% 3-4 times 14.7% None 32.6% 2 times 15.6% 1 time 27.8% Previous treatment history by race/ethnicity 34.1% 26.2% 21.9% 40.3% 47.6% first timer 65.9% 73.8% 78.1% 59.7% 52.4% repeater White Black American Indian Hispanic API Alcohol was cited as the primary substance of abuse by just over half of patients in treatment programs. Marijuana was the next most common primary drug of abuse mentioned by 1 in 5 patients, followed by methamphetamine and crack/cocaine. Primary substance of abuse varies by age of patients. Among youth in treatment, more than three quarters cited drugs as their primary substance of abuse with the majority of them being marijuana. Alcohol was the primary substance of abuse for only 15% of youth in treatment programs. However, alcohol was cited more often as the age of patients increased, accounting for more than 8 of senior admissions (ages 65 and older). Citation of marijuana, on the other hand, decreased with age from 7 of youth to less than 4% of senior patients citing marijuana as their primary substance of abuse. Among young adults, just over one third (36%) cited alcohol as their primary substance of abuse, 34% cited marijuana, and 21.7% cited methamphetamine. Crack and cocaine 30

31 were mentioned mostly by adults between the ages of 25 and 64 (13% of adults between the ages of 25 and 44 and 1 of those between 45 and 64). Primary substance of abuse Crack/ Cocaine 9.4% Other 6.1% Methamphetamine 12.4% Alcohol 50.6% Marijuana 20.5% 2.3% Primary substance by age group 4.2% % 5.2% 10.4% 3.4% 10.3% 33.8% 13.1% 3.2% 3.6% 2.5% 2.5% 69.8% % 21.7% % 12.5% % 86.3% other marijuana crack/cocaine meth alcohol 15.1% Under There are some variations among racial/ethnic groups with respect to primary substance of abuse, too. Alcohol was the primary substance of abuse for more than half of white, American Indian, and Hispanic patients, and marijuana was their leading drug of abuse. Black Minnesotans showed a peculiar pattern. Among black patients, crack/cocaine was the most cited substance of abuse closely followed by alcohol and marijuana. For just under 7 of black patients, drugs were the precipitant for treatment. Similarly, the majority of Asians and Pacific Islanders cited drugs, not alcohol, as their primary substance of abuse with marijuana and methamphetamine being the two leading drugs. 31

32 Methamphetamine was cited more by Asians/Pacific Islanders and white patients compared to the other racial/ethnic groups. Primary substance by race/ethnicity 5.9% 7.9% 6.3% 3.7% % 5.5% 15.3% 23.5% 23.2% 25.8% 5.7% 10.2% 5.5% 7.3% 35.8% % 20.2% other marijuana crack/cocaine 0.8% 54.4% 59.2% % 37.9% meth alcohol White Black American Indian Hispanic API Just over one-third of patients in 2004 (34.1%) were referred to treatment by court order. Overall, 48% of Hispanic patients were in treatment by court order, followed by American Indians and Asian/Pacific Islanders (41% each), whites (33%) and blacks (32%). Youths were more likely to be in court-ordered treatment than adults across all racial/ethnic groups except white; this makes the difference between white and minority patients even larger among youth. Black youths entered treatment through court order more than other youth patients, whereas Hispanic adults entered treatment through court order more than other adult patients. 66.8% Patients in treatment under court order 33.2% 55.3% % 46.9% 37.8% 38.3% 32.9% 30. White Black American Indian Hispanic API youth adult 32

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