Racial Disparities in Completion Rates from Publicly Funded Alcohol Treatment: Economic Resources Explain More Than Demographics and Addiction Severity

Reducing racial and ethnic disparities in health is a national priority with large potential benefits to the nation (U.S. Department of Health and Human Services 2000). Reducing mortality among African Americans to levels experienced by white Americans would have prevented over 880,000 deaths between 1991 and 2000 (Woolf et al. 2004). Racial disparities in alcohol-related morbidity and mortality are of special concern given the relationship between alcohol consumption and numerous other health conditions. Alcohol consumption is causally related to more than 60 medical conditions and responsible for about 4 percent of the global burden of disease, roughly the same share of death and disability attributable to hypertension or tobacco consumption (Room et al. 2005). In the United States, approximately 8.5 percent of adults meet Diagnostic and Statistical Manual of Mental Disorders 4th Edition criteria for alcohol abuse or dependence (Grant et al. 2004). The considerable burden of alcohol-related health problems falls disproportionately on African American and other minority populations, who have two to five times the rate of alcohol morbidity and mortality than whites, despite similar lifetime prevalence of frequent problem drinking (Group for the Advancement of Psychiatry 1996; Caetano 2003; Grant et al. 2004). Racial disparities in adverse drinking consequences to health are not well understood and could result from a number of factors, including differences in access to health care, economic resources generally, social and cultural practices, and drinking preferences and patterns (Blendon et al. 1989; Mayberry et al. 2000; Williams and Collins 2001; Caetano 2003; Fiscella and Williams 2004; Bluthenthal et al. 2005). Differences in alcohol treatment services are another potential explanation. Generally, treatment for alcohol abuse and dependence has been shown to reduce medical problems and medical care expenditures (Holder and Blose 1992; Holder et al. 2000). However, rates of publicly funded treatment utilization among African Americans and Hispanics were already nearly twice the rate of whites in the United States as of the mid-1990s, reversing a pattern of comparatively lower utilization in earlier decades (Group for the Advancement of Psychiatry 1996). Whether racial differences in the effectiveness of treatment exist has yet not been adequately studied. The few studies that have examined the issue have produced mixed results. For example, in Project Match, a clinical trial that randomized alcohol treatment clients to three psychosocial therapies, racial differences in treatment adherence were eliminated after controlling for occupation (Tonigan 2003). A small number of naturalistic studies have also found lower retention for African Americans compared with whites, but in no case have these findings prompted adequate discussion or a follow-on research study (Wickizer et al. 1994; Veach et al. 2000; Hser et al. 2001). In this article, we compare rates of treatment completion among white, African American, and Hispanic patients with alcohol problems at all publicly funded outpatient and residential treatment programs in Los Angeles, which, after New York, is home to the largest publicly funded system of drug and alcohol treatment services in the nation (U.S. Department of Health and Human Services 2003).1 We aim to establish whether significant differences in completion of alcohol treatment exist and whether differences in patient characteristics are related to any racial differences in treatment completion rates identified. Three research questions guide our analysis: Are African American and Hispanic patients less likely to complete treatment than white patients? Do African American, Hispanic, and white patients differ in ways that would be expected to lead to differences in treatment completion based on the treatment literature? if so, to what extent can differences in patient factors explain differences in completion? We hypothesize that four sets of characteristics previously associated with treatment outcomes are related to racial/ethnic differences in treatment completion: demographics; addiction severity; economic resources; and source of referral, particularly when resulting from legal involvement. While particular studies have documented associations between each of these characteristics and retention (e.g., McClellan et al. 1994; Wickizer et al. 1994; Young and Belenko 2002), findings in the retention literature have varied from sample to sample. To date no set of predictors that is consistent across samples has been identified. The positive effect of legal coercion into treatment on treatment retention is probably the most consistent finding in this literature (Anglin and Hser 1990).