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Foreword

The 1996 Award for Excellence papers are a culmination of the third Call for Papers from the Center for Substance Abuse Treatment (CSAT) and the National Rural Institute on Alcohol and Drug Abuse (NRIADA). The Call for Papers recognizes that States and counties in rural and frontier areas face special challenges in providing their citizens with adequate services and skilled treatment providers. These challenges call for innovative, unusual strategies and approaches and, in this current period of State health care reform, for solutions designed to work in rural areas (with 50 or fewer people per square mile) and frontier counties (with 6 or fewer people per square mile). In addition to describing the initiative, strategy, or program in depth, authors responding to the Call for Papers were asked to discuss problems and barriers that were encountered.

The papers that are published here offer a compelling look at a number of ways in which rural and frontier America is addressing alcohol and other drug abuse and the problems that accompany the abuse. Recognizing the efforts of AOD experts, caregivers, and communities in rural and frontier areas is one important goal of the Award for Excellence. Representatives of CSAT and NRIADA presented awards to the authors of the first, second, and third place papers at the National Rural Institute on Alcohol and Drug Abuse held in Eau Claire, Wisconsin in June 1996. David M. Paschane accepted the first place award for "Drug Use, Sexually Transmitted Diseases, and SexRelated Risk Behaviors in Alaska," which he wrote with Henry H. Cagle, Andrea M. Fenaughty, and Dennis G. Fisher. The second place award was presented to Boyd D. Sharp, Rodney (Roadrunner) Clarke, and Richard Pohl for their paper, "In Rural and Frontier America, It Takes a Whole Community to Rehabilitate a Substance Abusing Criminal." The third place award was accepted by Wayne Dougherty on behalf of Catherine E. Bartels, author of "Continuum of Services for Offenders in South Dakota." The awardees discussed their programs in workshops held at the Institute.

The Award for Excellence also brings recognition to other programs. The Ten Sleep, Wyoming community/school program, described in this volume, received an outstanding program award from NRIADA. Steve Sohm, who wrote "Prevention and Intervention Substance Abuse Programs in the Ten Sleep, Wyoming, School" accepted the award for Ten Sleep. Jim Armstrong of Bullhead City, who wrote about that community's strategies for building rural coalitions and networks in the 1994 Award for Excellence publication, received a community award at the Institute. Recognition of the accomplishments of the programs and strategies described in the Award for Excellence papers continues with the publication of these papers.

Communicating the ideas behind successful frontier and rural initiatives is the major focus of the Award for Excellence. Communication and access to treatment have traditionally been problematic in areas where populations are widely dispersed and hard to reach. Some of the Award for Excellence papers are beginning to reflect what may be a partial answer to these problems.

Some experts in rural areas believe that telecommunications technologies are key to resolving problems of access and fostering development in rural areas. According to a recent General Accounting Office report (Rural Development: Steps Towards Realizing the Potential of Telecommunications Technologies, GAO/RCED96155, June 1996), advanced telecommunications technologies—the Internet, videoconferencing, and highspeed data transmission—offer rural areas the opportunity to overcome their geographic isolation, take advantage of expertise in other communities, improve medical services, create new jobs, and improve access to education. The opportunities provided by these new technologies are also beginning to have an impact on the delivery of substance abuse services, as is reflected in some of the papers offered here.

For instance, Angeline Bushy notes the availability of peer support, consultation services, and educational courses via electronic media to rural service providers. She cites collaborative efforts between educational institutions and health care agencies made possible by the new technology. As described by Paul Higbee and Ernest Bantam, the Black Hills Careers Academy in South Dakota, a school for rural youth whose lives have been disrupted by substance abuse, encourages students to use the Internet to broaden their view of who they are and to explore potential careers. Kathryn Puskar and her colleagues describe a system in which rural school personnel could transmit data to a university computer for analysis.

In these rapidly changing times of health care reform, and the adjustments that Federal, State, county, and local jurisdictions are making in their delivery of substance abuse services, exploring new ways of communicating about and delivering AOD care makes a great deal of sense. Telecommunications technologies are one avenue for exploration. The papers presented here offer other avenues for thoughtful exploration of techniques that may be useful to communities searching for approaches to the problems associated with AOD use. Working in partnership together, we believe that we will successfully address the complex problems that we face.

David J. Mactas Director Center for Substance Abuse Treatment

Larry Monson Coordinator National Rural Institute on Alcohol and Drug Abuse

Award for Excellence Review Panel

Barbara Groves, M.M.
Project Coordinator
Oregon Together!
Office of Alcohol and Drug Abuse Programs
Salem, Oregon

Vicki L. Lentz
Green Country Mental Health Services, Inc.
619 North Main
Muskogee, Oklahoma

Larry W. Monson, ACSW
Coordinator
National Rural Institute on Alcohol and Drug Abuse
Tony, Wisconsin

Leon PoVey
Director
Utah Division of Substance Abuse
Salt Lake City, Utah

Steve Riedel, M.S. Ed.
Associate Director
Our Home, Inc.
360 Ohio SW
Huron, South Dakota

The "Guide to Bringing Excelence to Substance Abuse Services in Rural and Frontier America" could not be suitably transferred electronically. To obtain a copy of this guide, you can order this TAP by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or by accessing http://www.health.org/pubs/catalog/orderFrm.htm
The reference number for this TAP is BKD220.

Drug Use, Sexually Transmitted Diseases, and Sex-Related Risk Behaviors in Alaska

David M. Paschane, B.S.
Henry H. Cagle, B.S.
Andrea M. Fenaughty, Ph.D.
Dennis G. Fisher, Ph.D.
Department of Psychology
University of Alaska Anchorage
Anchorage, Alaska

Abstract The association between illicit drug use and sexually transmitted diseases (STDs) is well established in the literature; however, little is known about the networks of disease transmission among rural drug using populations. This paper explores issues related to STD risk among hidden, drug using populations. A structured interview was administered to 1,088 out-of-treatment, drug using adults. The sample included a large proportion of Alaska Natives and American Indians. Several descriptive statistics illustrate associations between sex-related risk behaviors, drug use, and disease transmission. Treating self-reported history of gonorrhea infection as a possible indirect indicator of STD/HIV risk, predictors of infection were identified through logistic regression modeling. The characteristics of drug users most likely to have reported gonorrhea infection were (a) a history of snorting or injecting cocaine, (b) income from prostitution, (c) being black as compared with being non-black, (d) a history of using nonheroin opiates, and (e) being in a younger age group. The model also included an interaction between prostitution and age. This paper includes a discussion of issues related to barriers to treatment and rural-urban mobility.

Alaska, the northernmost territory in the United States, with a population density of one person per square mile, has characteristics that are common to many other rural States (Cordes 1989). Alaska has a stressed primary economic base, underdeveloped infrastructure for accessing health care, and many isolated communities. Hence, delivery of health services and the operation of research in Alaska is challenging. Anchorage, Alaska's largest metropolitan area, is a centralized source of health care and other human services, as well as free shelter and food for a large disenfranchised population. As a result, Anchorage attracts populations migrating from rural Alaska. Seasonal employment opportunities and the centralization of service-oriented jobs also contribute to the high levels of migration. In addition, Anchorage attracts those populations seeking to purchase drugs or participate in drug-related activities (e.g., prostitution). These conditions, plus the necessary resources required for effective research, suggest Anchorage as an opportune and cost effective place to sample Alaskan drug users.

Drug abuse and its contribution to diseases is a growing concern in rural communities throughout the United States. Diseases associated with illicit drug use, such as AIDS and other sexually transmitted diseases (STDs), have stimulated health professionals' interest in implementing prevention models among drug using populations. Injection drug users (IDUs) have been commonly recognized for contributing to the spread of hepatitis and HIV. In a collection of ethnographic studies, Ratner (1993) describes the relationship between trading sex for drugs or money and smoking cocaine (i.e., crack; Ouellet et al. in press), and illustrates the potential risk of disease transmission where drug use and sex behaviors are combined. Other factors contributing to HIV/ STD risk, besides an increase in the number of sex partners, are genital ulcer disease caused by an earlier STD (Chirgwin et al. 1991), genital tissue damage (e.g., penile abrasion), and ulcers in the mouth from cocaine smoking burns (Ratner). The levels of risk for STDs at locations where cocaine smokers trade sex have been equated with risk in the gay bathhouses of the past (Goldsmith 1988).

STDs are among the most common infectious diseases (CDC 1994), affecting more than 13 million adults in the United States (NIAID 1992). These contribute to a sizable morbidity and mortality, place a significant burden on medical services, and have an estimated annual cost of $5 billion (NIAID). The decreases of screening resources in the United States (Yankauer 1994) may further complicate the burden of STDs for rural populations because of barriers to health care access (Steel and Haverkos 1992). Additionally, drug users may be at a greater disadvantage because of individual resistance to access services if they fear disclosure and consequences for their drug using behaviors (Haverkos 1991). These conditions mean that better targeting schemes are necessary when attempting to control the prevalence of diseases among high-risk populations. Watters (1993) recommends targeted sampling of the noninstitutionalized hidden populations in order to provide information leading to indicators of infection rates and behavioral risks associated with STDs.

Alaska has a unique history of STDs. They were an important cause of illness and sterility as early as the 1700s, when they were first introduced to the Native populations by Europeans (Fortuine 1989). The earliest reports of a behavioral association with STDs are alcohol consumption and sex-related risk behaviors (Fortuine). Historically, gonorrhea (GC) rates have been an important surrogate indicator of HIV risk and other STDs in Alaska. Because chlamydia is not a reportable disease and syphilis rates (1.34 per 100,000) are too low to be reliable indicators, GC rates are the most reliable long-term indicators of unsafe sexual behavior. Twenty years ago, Alaska's GC rates were the highest in the Nation (Eisenberg and Wiesner 1976). These rates have since declined and are now similar to other rural States where GC is below the national objective of the Centers for Disease Control and Prevention (CDC 1994). However, the incidence of GC is high among some groups in Alaska. In 1993, a total of 676 cases of GC were reported with an overall rate of 115 per 100,000; highest rates were among 15- to 19-year-old women, 834 per 100,000; and blacks, 894 per 100,000 (State of Alaska HIV Prevention Planning Group 1995).

The potential for reinfection makes GC fundamentally different from most other bacterial STDs. Some factors contributing to the prevalence of GC are (a) the host's lack of acquired immunity, (b) the potential for asymptomatic infection, and (c) its unique biological makeup (Bignell 1994). Asymptomatic-infected persons are believed to contribute disproportionately to the perpetuation of GC (Upchurch et al. 1990). Moreover, the dramatic increases of penicillin-resistant strains occurring in many regions of the United States may increase the rates of GC prevalence (CDC 1994; Gorwitz et al. 1993; Handsfield et al. 1989). Beller et al. (1992) found that nearly 34 percent of the multiple GC infections in Alaska were among a core group of infected individuals. The existence of a core group may suggest a network of disease transmission among a specific population not easily recognized by traditional surveillance methods.

Behavioral characteristics have been reported to be associated with GC (Beller et al. 1992; Handsfield, et al. 1989; Schwarcz et al. 1992; Upchurch et al. 1990) and other STDs (Booth et al. 1993; Chirgwin et al. 1991; Kim et al. 1993; Marx et al. 1991; Richert et al. 1993). The behaviors associated with STD acquisition can be both direct (e.g., deliberate unprotected sexual contact) and indirect (e.g., drug use leading to unprotected sexual contact). The relationship between drug use and sexual behavior is often due to the context in which drugs are obtained and the extent of the drug user's perceived need; that is, a compulsive urgency for those drugs and willingness to take greater sexual risk (Ratner 1993; Zinberg 1984). At this time, there is little known about these behaviors and their relationship to diseases in Alaska. Even though Alaskans have long had a reputation for high alcohol consumption rates, the high rates of drug use have been underreported (Fisher and Booker 1990), and even less is known about the networks of disease transmission among these drug users.

Haverkos (1991) argues that the integration of drug abuse and STD treatments would improve the effectiveness of public health interventions directed at controlling STDs. Support for this argument has been tested by clinical trials among intravenous drug users (Umbricht-Schneiter et al. 1994). The overall purpose of this study was to describe those factors that may better explain the networks of disease transmission among rural drug using populations. This required an illustration of associations between sex-related risk behaviors, drug use, and disease transmission. Even though clinical and surveillance data are normally a primary source of STD information, neither source of data reflects the correlates of STDs as they are found among specific high-risk populations (Anderson et al. 1994). In addition to the associations, a risk profile for a possible indirect indicator of high-risk behaviors (i.e., GC) will be modeled for the purpose of better describing the subgroup of the population most responsible for the disease network (Yorke et al. 1978) in a transitional rural population. Because of GC's epidemiological nature, it is an appropriate indicator and allows for such exploratory modeling and targeting of a high-risk hidden population.

Method

This research is part of a longitudinal, multisite study of out-of-treatment cocaine smokers and injection drug users at risk for HIV acquisition and transmission. The National Institute on Drug Abuse Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program is designed to assess the efficacy of a locally developed enhanced intervention compared with a standardized intervention for HIV risk reduction. Participant recruitment for this study was guided by a targeted sampling plan based on Watters and Biernacki (1989).

All research activities occurred in an office-based setting, the Drug Abuse Research Field Station. Participants provided informed consent under a Federal Certificate of Confidentiality and received monetary compensation for their time in research. Individuals eligible for research participation were at least 18 years old and self-reported (a) no drug treatment in the preceding 30 days, (b) injecting heroin, non-heroin opiates, cocaine, or amphetamines, and presented needle track marks indicative of recent injection drug use, or (c) cocaine smoking and produced positive urinalysis for cocaine metabolites. Participants routinely received urinalysis screening for cocaine metabolites, morphine, and amphetamines (Abusescreen ONTRAK; Roche Diagnostic Systems, Montclaire, NJ).

Data in this study are cross-sectional, with participant recruitment and data collection beginning in November 1991 and ending in August 1995. Dependent and independent (predictor) variables were drawn from the Risk Behavior Assessment (RBA) (National Institute on Drug Abuse 1991). The RBA is a structured interview that elicits demographic, alcohol and illicit drug use, drug treatment, sexual behavior, health, criminal activity, and income information. Most of the RBA questions are phrased to use a time reference of the last 30 days, followed by lifetime, the last 48 hours, and the last year. History of sexually transmitted disease is assessed by responses to two items: (a) the number of times participants report being told by a doctor or nurse that they had the specific STD, and (b) the year they report last being treated. The RBA has good test-retest reliability on the drug use and sexual behavior variables (Fisher et al. 1993b; Needle et al. 1995) and high validity coefficients on the drug use variables (Dowling-Guyer et al. 1994; Weatherby et al. 1994).

All scientifically relevant RBA variables were considered for analysis. For the purpose of these analyses, some recoding of the variables was necessary. Categorical variables were either dummy coded or coded dichotomously; continuous variables were maintained, but those with skewed distributions were coded dichotomously. Statistical tests that were applied to the data included: (a) Student's t test, (b) Pearson chi-square, (c) categorical modeling analysis, (d) ordinal logistic regression analysis, and (e) a binary response exploratory logistic regression analysis. All analyses were performed using the SAS System (SAS Institute Inc. 1990). Logistic regression model building and regression diagnostics were performed using techniques developed by Hosmer and Lemeshow (1989).

Barriers

There are a number of common criticisms of self-reported survey data: (a) underreporting due to asymptomatic infections, (b) unwillingness to discuss sensitive subject matter, and (c) inability to recall disease information provided by a medical provider (Anderson et al. 1994). However, clinical studies and surveillance data rarely include assessments of risk behaviors. The outcome variable in this study is self-reported history of STDs, and this may introduce undesirable measurement error to the model. Reliability of self-report is believed to be high when the RBA instrument is utilized (see Method). The validity of self-reported hepatitis infection has been investigated (Fisher et al. 1996), and findings suggest underreporting. The same problem may be present for other infections.

In order to minimize the effect of misreporting specific STDs, responses to number of times participants reported being told by a doctor or nurse they had an STD (i.e., gonorrhea, syphilis, genital warts, chlamydia, and genital herpes), including hepatitis B, were aggregated. The data were recoded because of the nonnormality of the distributions. The resulting variable had three categories: (a) no history of STDs, (b) history of one STD, and (c) history of multiple STDs. Drug- and sex-related risk behaviors having occurred 30 days preceding the interview were defined as recent behaviors. Drug use was categorized as those who only injected drugs, those who only smoked cocaine, and those who did both. Earlier studies have demonstrated high validity on drug use variables (see Method). The sex-related risk behavior variable consisted of four categories: (a) traded sex for drugs or money, (b) traded drugs or money for sex, (c) participated in both items a and b, and (d) did not participate in either item a or b. Utilizing the Dowling-Guyer et al. (1994) data, separate reliability analyses were performed on the GC variable. Test-retest reliability coefficients for number of times (r = .94; n = 222) and year treated (r = .93; n = 64) were both substantial. Test-retest reliability analyses were also conducted by gender. Among women, reliability coefficients for number of times (r = .95; n = 57) and year treated (r = .99; n = 15) were only slightly greater than those for number of times (r = .94; n = 164) and year treated (r = .91; n = 48) for men. For logistic regression modeling, GC was recoded as "ever" or "never" because of similar use of the variable in previous research (Kim et al. 1993; Schwarcz et al. 1992; Upchurch et al. 1990).

Many of the methodological recommendations identified by Marx et al. (1991) in their review of studies reporting associations between sex, drugs, and STDs risk (e.g., comparison to uninfected group, specification of drugs used, nonminorities, and rural populations) are addressed in this study. Due to overall sample size, model replication could not be attempted within this sample; therefore, it is recommended that similar modeling be attempted using other samples of drug users.

Findings

The study sample (N = 1,088) consisted of 740 men (68 percent) and 348 women (32 percent). The mean age was 35.1 years (SD = 7.6) for men and 32.8 years (SD = 7.4) for women, t(1,086) = 4.71, p < .0001. A summary of selected characteristics of the study sample is included in table 1. More whites (43 percent) participated than other race groups; however, a greater proportion of blacks (31 percent) and American Indians/Alaska Natives (AI/ANs; 20 percent) participated than are represented in the Municipality of Anchorage, 6 percent each (Municipality of Anchorage, Community Planning and Development Department 1993). A majority of participants were not homeless (82 percent) and described themselves as heterosexual (93 percent). Levels of education are distributed almost evenly over these categories: (a) less than high school (36 percent), (b) high school or its equivalent (35 percent), and (c) greater than high school (29 percent). The most frequently reported STD was GC (36 percent), followed by hepatitis B (15 percent), chlamydia (14 percent), genital warts (10 percent), syphilis (5 percent) and genital herpes (5 percent). Perceived risk for HIV infection (n = 1,046) was skewed toward none to some chance, with only 27 percent perceiving themselves having half or a high chance of infection.

Table 2 contains a summary of drug use and sex-related risk behaviors by history of total number of STDs. Results of the multivariate categorical modeling utilizing the weighted-least-squares analyses indicated that the main effects were significant for both the trading variable, c2 (6, N = 1,088) = 55.89, p < .001, and the drug using variable, c2 (4, N = 1,088) = 16.54, p < .01; however, the interaction parameter was not significant. The reduced model excluded the interaction term.

Among the 12 possible risk categories (i.e., the interaction between trading behaviors and drug using behaviors), the largest proportions were among those with a history of no STDs and history of multiple STDs. Fifty-six percent of those who did not trade and reported smoking cocaine only (n = 408), and 48 percent of those who traded only money/drugs for sex and only smoked cocaine (n = 194), reported histories of no STDs. Fifty-seven percent of participants who traded sex, smoked cocaine, and injected drugs (n = 38), and 49 percent of those who traded sex, traded money/ drugs for sex, and only smoked cocaine (n = 39), and 47 percent of those who traded sex and only smoked cocaine (n = 122) reported histories of multiple STDs.

The most parsimonious ordinal logistic regression model of risk factors, where all three levels of the response variable (history of STDs) are represented, retained two significant risk categories (i.e., trading behavior by drug use) and one protective factor: (a) traded sex, smoked cocaine, and injected drugs (OR = 2.67; CI = 1.41, 5.05), (b) traded sex, and only smoked cocaine (OR = 1.73; CI = 1.20, 2.50), and (c) did not trade, and reported smoking cocaine only (OR = 0.53; CI = 0.41, 0.68). Results of the analysis are reported in table 3. The effects of the combined behaviors multiply the odds ratio for either of the comparisons of the combined response variables represented by Constant A (multiple STDs versus one and no STD) and Constant B (multiple and one STDs versus no STDs).

Table 3. Ordinal logistic regression model for predicting sexually transmitted diseases among Alaskan drug users
(N=1,088)

Factor	ß	SE(ß)	OR	95% CI
Constant A	-0.73***	0.09
Constant B	0.35***	0.08
Trade sex, inject, smoke cocaine	0.98**	0.32	2.67	1.41, 5.05
Trade sex, smoke cocaine	0.55**	0.19	1.73	1.20, 2.50
No trade, smoke cocaine	-0.64***	0.13	0.53	0.41, 0.68
	**p<.01. ***p<.001 SE=standard error; OR=odds ratio; CI=confidence interval.

Results of the exploratory logistic regression analysis modeling predictors of GC infection are presented in table 4. Risk factors for GC were (a) a history of snorting or injecting cocaine (OR = 2.31; CI = 1.20, 4.43), (b) income from prostitution, (c) being black as compared with being non-black (OR = 1.79; CI = 1.34, 2.40), (d) a history of using other opiates (OR = 1.55; CI = 1.18, 2.03), and (e) being in a younger age group. Table 5 shows the interaction of age with income from prostitution; presented are the odds ratios for having income from prostitution. The Hosmer-Lemeshow goodness-of-fit tests (Hosmer and Lemeshow 1989), c2 (8) = 8.16, p = .42, demonstrated adequate model fit.

Table 4. Logistic regression model for predicting gonorrhea among Alaskan drug users
(N=1,083)

Factor	ß	SE(ß)	OR	95% CI
Constant	-3.19	0.45
Cocaine (snort, inject)	0.84	0.33	2.31	1.20, 4.43
Blacks	0.58	0.15	1.79	1.34, 2.40
Opiates (non-heroin)	0.44	0.14	1.55	1.18, 2.03
Prostitution	4.45	1.47
Age	0.05	0.01
Prostitution x Age	-.011	0.05

Note: Change in N due to missing observations. See Table 5 for estimated odds ratios and 95 percent confidence intervals for prostitution, controlling for age.

OR=odds ratio; CI=confidence interval.

Note. Odds are the ratio of the odds of gonorrhea infection among those reporting income from prostitution, to the odds of gonorrhea infection among those reporting not receiving income from prostitution (age is set to four levels). Change in N is due to missing observations.

OR=odds ratio; CI=confidence interval.

Conclusions

Results confirmed prior hypotheses that associations exist between sex-related risk behaviors, drug use, and STDs in rural populations (Forney et al. 1992; Steel and Haverkos 1992; Thomas et al. 1995). In this case, a history of multiple STDs was best predicted by those who engaged in trading sex for drugs or money and smoked cocaine. Cocaine smokers who did not trade sex for money or drugs were more likely than any other group to have reported no STDs. Almost half of those who were trading money/drugs for sex and smoking cocaine had no STDs. These findings suggest that although drug users are commonly considered at high risk for STDs, not all drug users represent the core group perpetuating STDs in a given rural population. Accurate identification of those most likely to represent the source of STDs and diseases spread through injection drug use can make targeted interventions most effective. The associations described herein illustrate the several possible profiles for STDs within drug using populations. Trading sex for money or for drugs was a component of both groups with significant odds ratios for multiple STDs. The two groups each smoked cocaine; one also injected drugs. These findings support Ratner (1993), in that trading sex and smoking cocaine is the most significant risk combination for STDs. Even though half of those who smoked cocaine, traded sex, and purchased sex with money or drugs (n = 39) reported multiple STDs, this group was not a significant predictor in ordinal modeling. This would suggest that at least half of this group, who have resources to both sell and buy sex, also have characteristics that reduce risk status.

Prostitution, especially among AI/ANs, has received little attention in Alaska. This may be due to the belief that high-risk sexual behaviors (i.e., prostitution) are primarily a characteristic of urban populations (Forney et al. 1992). In addition, rural populations are stereotypically thought of as members of isolated communities where trading sex is not relied upon for economic survival. Anchorage attracts many AI/ANs seeking treatment and assistance resources, and they may be at risk of separation from their traditional community norms that prevent further risk behaviors. The AI/AN women in this cohort often report multiple sex partners, unsafe sex practices, and high-risk drug using behaviors (Fenaughty et al. 1994; Fisher et al. 1993a). Recent reports found that among a sample of drug using women, AI/ANs were more than two and a half times likely to have had GC (Paschane et al. in press) and nearly two times more likely to have had chlamydia (Orr et al. 1995). Conway et al. (1992) describe a potential diffusion of HIV and STDs into rural populations of AI/ANs and suggest this may be due to regular migration between rural and urban areas.

The predictors identified in the GC model better define the hidden, high-risk population for STDs. The model includes two factors often reported in the literature, being black compared with other race groups (Kim et al. 1993; Upchurch et al. 1990), and a history of cocaine use (Marx et al. 1991; Schwarcz et al. 1992). Being black, as a risk factor for GC, agrees with surveillance data in Alaska where GC infection rates among blacks are highest (see the Introduction). Gershman and Rolfs (1991) suggest that race may be a surrogate marker for high-risk behavior, and if race is better defined (i.e., cofactors are identified), it may further describe the core group. A history of using non-heroin opiates has been reported to be associated with ethnicity (whites compared to blacks and AI/ANs; Cagle et al. 1996), infection with hepatitis B (Kuhrt-Hunstiger and Fisher 1994), and a history of chlamydia infection (Orr et al. 1995). The presence of non-heroin opiate use in the model may account for those non-blacks with a history of GC. More research is needed to explain the association between non-heroin opiate use, and risk for GC.

The interaction between age and income from prostitution is an interesting risk factor and may further explain the findings presented in this paper. If individuals who are trading sex for drugs or money and smoking cocaine are most likely to have had multiple STDs, then the age distribution of this population may further explain the disease network. The odds ratios illustrate the interaction by considering risk from prostitution at four age levels. The youngest age group of 20 years is more than nine times as likely to have had GC. Such a dramatic ratio of the odds between those reporting income from prostitution, and those who did not, suggest that this sex-related risk behavior may best define the core risk group in a rural population. These findings are further supported by the surveillance data reporting 15- to 19-year-old women as having one of the highest rates of GC in Alaska (see the Introduction).

Surprisingly, the pattern is contrary to the expected condition in which older age would be associated with history of GC because of the greater opportunity to contract the disease; however, this may also illustrate risk behaviors unique to younger sex-workers. Koester and Schwartz (1993) report that condom use was least among women trading sex directly for smokable cocaine versus women who traded sex for money. This same group may experience a number of conditions that increase their risk for multiple STDs, such as decreased power for negotiating safe sex practices (Worth 1989), being homeless (Zhao et al. 1995; Paschane et al. in press), and being poorly educated (Zhao et al.). Because asymptomatic-infected persons are believed to contribute disproportionately to the perpetuation of GC (Upchurch et al. 1990), it is possible that the non-drug users who purchase sex from the younger sex-workers may become infected, remain asymptomatic, and unknowingly transmit STDs to other members of the non-drug using population. Whether being older is a protective factor among prostitutes (OR = 0.34) is unclear and may require further investigation.

The models reported here better describe risk factors for GC and multiple STDs in a sample commonly believed to be at high risk for HIV and other STDs. Having unique risk profiles for GC may benefit public health professionals developing HIV/STD interventions in Alaska and other rural States. Future studies should investigate the strength of these associations in describing the populations of other rural areas. Such research may provide additional insights into the prevention of disease transmission where characteristics of populations vary. Two issues relevant to the control of STDs in rural areas are rural-urban mobility as it applies to disease prevalence and barriers to treatment services that control disease.

Haverkos (1991) contends that the integration of drug and STD services will best serve the public health need to control the ever-increasing rates of STDs and drug use. Rural locations, where resources are even more limited than their urban counterparts, can benefit from effective integration of services. The resistance that individuals may have to access services where they fear disclosure and consequences for their drug using behaviors (Haverkos 1991) may worsen the effects of these public health burdens. Barriers to treatment services (Steel and Haverkos 1992) are a reality for drug users in Alaska (Johnson et al. 1995). Common treatment barriers reported by Johnson et al. are excessive cost, lack of availability, inaccessible location, nonculturally relevant programs, and lack of child services. Service integration may help to better overcome some of these barriers experienced by drug users. A subgroup described at even more risk is those with psychiatric illness other than drug or alcohol use (Johnson et al.). In cases in which individuals are less able to make decisions regarding their welfare, mental health agencies, in cooperation with drug treatment centers, may help overcome this barrier to treatment.

As mentioned earlier, migration from rural communities to urban centers for accessing treatment, is, for some individuals, the only choice when services are centralized and local services are inadequate. Recent reports have recognized a significant amount of migration to Anchorage by AI/AN women (Fisher et al. 1993a; Fogel-Chance 1993; Hamilton and Seyfrit 1994). It is unclear what effect migration has on STD/HIV risk; however, other data suggest that behavioral trends among AI/ANs are leading to destructive outcomes. For example, the highest rates of suicide are among AI/AN men (Berman and Leask 1994), and a majority of those are intoxicated at time of death (Soule 1994). Fisher et al. (1995) also report a number of significant high-risk behaviors among AI/AN women that may be due to the effects of migration. Williams et al. (1993) suggest that travel patterns among drug users may increase the HIV risk to other populations (e.g., rural, non-drug users). Because rural areas contain seasonal employment and subsistence opportunities and most health and human services are centralized, migration is likely to continue in this population.

Recommendations

This study illustrates findings that are useful for developing targeting schemes for STD/HIV interventions. As budget reductions continue (Yankauer 1994), effective management of diseases requires accurate identification of core risk groups. For example, interventions are often designed for the purpose of serving those individuals most likely to seek treatment rather than the populations practicing high-risk behaviors. As a result, members of core groups responsible for the prevalence of STDs may not receive the treatment and counseling necessary for controlling further transmissions of the disease. One way to improve the likelihood of treatment among these high-risk populations is to plan coordinated referrals for treatment among public service agencies. If agencies are better equipped to make active referrals and have the opportunity to recognize the high-risk individuals, they can improve the likelihood of STD control. Future alterations to intervention programs should target the high-risk rural populations and find means of improving their access to testing and treatment.

A number of changes have been made to local STD/HIV screening and treatment services in an effort to reduce the STDs in this study population. A public health nurse (M.A. Lee, personal communication, February 8, 1996) and an HIV outreach worker (M.R. Covone, personal communication, February 8 1996) have attended social gatherings where members of high-risk populations are known to congregate (i.e., bars, massage parlors, the bus station) and performed HIV testing and risk reduction education. Peer outreach appears to be most effective; however, language barriers exist and may be addressed by including outreach workers with appropriate language skills. The most difficult group of drug users to screen for STDs, and at greatest risk as illustrated by these data, are those trading sex for drugs or money. This group may participate in sex-related risk behaviors during hours that cause them to sleep during the day and reduce the likelihood of accessing services during the same hours of operation. A mobile testing unit (e.g., van) operating during an evening shift may best improve access to testing for this high-risk group. Again, effective peer outreach is necessary because of the possible negative effect drug use may have in facilitating cooperation with these clients. Women trading sex are easier than men to target because they are more likely to walk the streets or work at massage parlors; men trading sex are more difficult to target because of lack of visibility. Further studies are necessary for identifying means of improving outreach to this population.

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In Rural and Frontier America, It Takes a Whole Community To Habilitate A Substance Abusing Criminal

Boyd D. Sharp, M.S., LPC
Consortium Executive Director

Rodney (Roadrunner) Clarke, Esq.
Consortium Board Chairman

Richard Pohl, Ph.D.
Consortium Evaluator

Klamath County Treatment and Correctional Providers Consortium
Klamath Falls, Oregon

Abstract This paper consists of three major parts. The first describes the treatment obstacles faced by substance abuse treatment providers and criminal justice system personnel in a small Oregon town. To overcome these obstacles, they created a network aimed at reducing substance abuse and drug-related crime by chronic repeat offenders. The coalition was successful in securing a CSAT grant to address this population, beginning a drug court program, assisting in developing a jail program, and is now being included in countywide criminal justice planning. The second part describes the CSAT funded project they created to fight substance abuse and crime. The project's treatment model is an intensive, outpatient, antisocial therapeutic community emphasizing the cognitive approach of Yochelson and Samenow. The third part presents data suggesting that the model created is effective at reducing arrests. In fact, arrest rates of clients in the program 9 months or more fell 88 percent from what they were in the 3 months before program entry. The reduced arrest rate was not caused by attrition of clients with the most severe alcohol/substance abuse problems. Over two-thirds of clients had lower arrest rates after they entered the program than before they entered it. The reductions in arrest rates increased the longer the clients were in the program. These results suggest that the Consortium model is effective on an outpatient basis.

This paper first describes the process by which the Klamath County Treatment and Correctional Providers Consortium was developed, including the research into the repeat offender problem in Klamath County. Second, from a therapy/corrective perspective, we outline implementation of an outpatient program for chronic nonincarcerated repeat offenders who have substance abuse problems. We describe the major components of treatment in this program, which is known as the Consortium treatment program. Third, we examine outcome studies and the latest demographic data on Consortium clients from an evaluative perspective.

Consortium Program Development

Background

Klamath County, in Southern Oregon, covers an area of 8,000 square miles of high desert and mountainous terrain. The population density is approximately nine persons per square mile, and agriculture and timber are the major industries. The rural community of Klamath Falls is the economic hub of the county. There are approximately 18,000 residents within the city limits, an additional 20,000 residents within the adjacent urban growth boundary, and 10,000 residents in outlying areas, for a total of 48,000 residents in the county. The primary minority populations are Native Americans and Hispanics, each comprising 5 percent of the county's population.

History

In the fall of 1991, an auspicious staff meeting of probation and parole officers employed by the Klamath County Department of Corrections took place. During the course of the meeting, Jackquelyn Hoffmann, a nurse employed by the sheriff's office at the Klamath County Jail, presented some astonishing and disconcerting information. Jacki presented statistics on repeat offenders arrested five or more times since establishment of a new local jail in the fall of 1989.

The statistics Jacki presented made it quite clear that an overwhelming proportion of local crime was being committed by the repeat offender population. The growing population of repeat offenders was exacting a disproportionate local cost in terms of personal and property damage, while causing social costs through creating an atmosphere of fear, concern, and frustration among local residents. Additionally, the sheer magnitude of the level and frequency of arrests was adding financial burdens to local government at all levels of operations of the criminal justice system, including investigation, arrest, prosecution, incarceration, and supervision.

Several difficulties in addressing the social and financial costs created by repeat offenders were discussed during the course of the corrections staff meeting. First, the State of Oregon had placed severe restrictions on the ability of probation and parole officers to send our clients to prison. In addition, due to severe financial difficulties of county government, the sheriff's office had lost approximately 40 percent of its active officers due to layoffs. Among the consequences of the layoffs and reduction in budget was the loss of two-thirds of the operating capacity of the local jail. Only one of the three jail pods was open, and a revolving door situation reflected our local inability to hold offenders for significant periods of time.

The consensus of the corrections staff was that more than 90 percent of the identified repeat offenders had histories of drug and/or alcohol abuse and/or dependence. Local financial capacities to treat these offenders were inadequate to cover more than one-quarter of actual treatment costs for corrections clients. There was complete agreement regarding the social and financial impact of the repeat offender population, the lack of adequate sanction capacity through either prison or jail incarceration, and the inadequacy of treatment resources. Discussions turned to possible solutions. Rodney (Roadrunner) Clarke, a Klamath tribal drug and alcohol program director, suggested, and parole officers and the agency director, Chuck Edson, agreed, to begin a cooperative effort to engage in the planning, community organizing, and fundraising necessary to address the repeat offender problem.

Chuck Edson enlisted the local sheriff's office and jail representation. Rod Clarke involved Stepping Stones, Lutheran Family Services, Consejos, and the other local treatment programs, as well as the County Department of Mental Health.

Jan Kelley, Stepping Stones planner, attended a regional workshop on new Center for Substance Abuse Treatment funds and reported her findings back to our planning group. CSAT funding appeared to be available and appropriate to our plans. For a full year, our coalition met at least monthly to discuss and plan a project intended to:

• Positively impact the target repeat offender population through treatment
• Improve local sanctioning capacities, especially at the county jail
• Increase funding to local treatment providers to enhance their capacity to treat the target population.

We followed our principles in planning the project. Although we could have designed program delivery to award the lion's share of funding to the four treatment providers involved in the planning, instead, we decided after analysis and discussion that a new and separate program with its own staff to focus on the target population would be more likely to be effective than would referrals to our own agencies. We designed our treatment program accordingly, providing the opportunity only for the providers to contract to perform group therapy.

A team of Consortium members traveled to Salem, Oregon for the first CSAT workshop on their new funding. We were pleased to discover that we appeared to be the embodiment of the community partnership model supported by CSAT policy and philosophy. However, we were surprised and disappointed to find that CSAT had made a change in programming and would no longer be accepting applications for projects at local jails outside Target Cities project sites.

We returned and called a Consortium meeting to discuss the situation and reconsider our direction. Captain Linville of the sheriff's office encouraged us to apply for a CSAT grant even though there would no longer be any financial benefit to the jail operation from a prospective grant. As a result, we developed a consensus to accelerate the frequency and duration of our planning meetings, targeting CSAT as a funding source to develop outpatient rather than incarcerated treatment for the target population.

Various proposal components were assigned to Coalition members, drafted, and brought back for discussion. Jan Kelley took the completed components and developed our actual proposal to CSAT. Ultimately, it was reported to us that CSAT received 198 proposals and funded a total of 13. We also found out that our proposal was reviewed favorably at CSAT. As a small rural community, with a diverse planning group involving the Hispanic and Klamath Tribal communities, as well as other established agencies and departments, we were and are very proud of our sustained planning efforts and proposal success.

After receiving our notice of award, the Coalition formally organized through the efforts of our membership as a nonprofit corporation. We applied for and received corporate status from the State of Oregon as the Klamath County Treatment and Correctional Providers Consortium, also referred to as The Consortium. We promptly filed for and received 501(c)(3) status as a charitable organization from the Internal Revenue Service.

Other Coalition Benefits

The Consortium, for nonincarcerated repeat offenders with five or more arrests, funded federally through the Center for Substance Abuse Treatment (CSAT), is the first project initiated by our broader local consortium of providers, criminal justice participants, and lay people. Of note is that the original long-term planning engaged in by the coalition participants has had significant and substantial additional benefits for our community.

As stated, one of the key original purposes of the coalition was the critical need to supplement jail operations capacities. Primarily through the efforts of Chuck Edson, the Klamath County Jail is now a regional facility funded in part by the financial contributions of departments of corrections from adjoining counties. A jail that once operated at one-third capacity now operates at two-thirds capacity or better.

Local coalition building and planning has also now become part of the fabric of our community. Klamath County Commissioners have formally appointed local individuals to a Criminal Justice Planning Committee as well as to a local Public Safety Planning Council. Both entities do comprehensive planning on behalf of local government, and both include many individuals from our original coalition. Treatment providers are now part of the criminal justice system, with treatment providers playing a central role in policy development. In the past, providers were included in such groupings and activities as an afterthought, if considered at all.

Finally, our coalition is gradually but constantly growing, to the benefit of our community as a whole. For example, local judges have recently become part of the loop by providing leadership and facilitating the development and implementation of a drug court out of local resources. The ripple effect of having cast our concerns into a pond of previous indifference is fully expected to continue. As with our Consortium treatment program, we expect to continue to improve the conditions and quality of life in our community through planning that follows our principles and coordinated, concerted, and comprehensive efforts.

Program Implementation

Beginning the Program

During the period between the grant's approval and the start of funding, a major destructive earthquake, 5.9 on the Richter scale with the epicenter about 15 miles from Klamath Falls, occurred. It eliminated the proposed physical location. As a result of the earthquake, the program lost the in-kind use of a county facility. The county courthouse was closed due to earthquake damage, and county departments immediately took up virtually all available space, a total of at least 30,000 square feet. Loss of the county facility forced staff and Consortium members to spend considerable time locating a building to house the project. This added $15,000 to $20,000 to the cost of the project. We are currently located downtown in a remodeled old office building.

Just as critically as the physical damage that it inflicted, the earthquake affected the psychological condition of the community. Worry and concern over personal impact was devastating to many. Recovery within the greater community was slow. The physical acts necessary in tearing down blocks of buildings and the emotional reminders of damaged buildings not yet torn down also had an impact on the community. Although an earthquake affects any community, in a rural and frontier area any major disaster touches practically every citizen because of the interrelatedness evident in rural and frontier communities.

The first executive director was hired in February of 1994, with other staff subsequently hired. There were delays in developing contracts between the County of Klamath, the State of Oregon, and the Board of Directors, which were needed to make CSAT funds available to the project. These delays cost the program a good 5 months of operation. In addition to the above, the first executive director resigned in September 1994 and the present director was not hired until December, causing further delay.

In this environment, trying to continue the original excitement, cooperation, and progress was difficult. The entire implementation process was relegated to a snail's pace. Nevertheless the commitment, dedication, and earnest efforts of the Board of Directors, the staff, and the community officials functioning as supporters was unwavering.

A clear outcome of the grant was furthering a team/community sense of purpose in the treatment and correctional personnel who had contact with the project staff. The grant served as a breath of fresh air in a professional community racked by budget cuts, personnel layoffs, and resource depletion. The sense of innovation and the rejuvenation produced by professional recognition of the problem in the community combined to involve and motivate the staff of the numerous agencies connected to the project. Given the overall attitude of this community, this has been a very noteworthy and positive outcome.

Program Description Revisited

The Project's ability to make an impact in Klamath County increased immensely with the hiring of a new executive director who had previous experience in developing and supervising a successful 50-bed alcohol and drug therapeutic community in a similar rural environment (Powder River Correctional Facility in Baker, Oregon).1 His arrival increased the possibility of developing a model that satisfactorily treats the nonincarcerated offender and reduces his or her reoffense rate, which in turn would reduce the overall crime rate in Klamath Falls.

Beginning on December 5, 1995, the program initiated a number of changes that improved program accountability and progress toward program goals. The project seriously reevaluated the initial program design. A move toward an antisocial treatment model, as opposed to a prosocial treatment model, was made. This model is described in Bush and Bilodean (1993), and Sharp and Beam (1995). The Hazelden's Design for Living series, which is designed to specifically address the offender population, was incorporated into the program format. Also incorporated was Yochelson and Samenow's Thinking Error material as a major portion of the program (Yochelson and Samenow 1976, 1977, 1986).

Antisocial Treatment Model

The program employs a cognitive-behavioral approach that includes strict use of sanctions for program rule violations, cognitive restructuring of criminal thought patterns, and a therapeutic community. The antisocial treatment model embraces (among other things) the belief that criminals commit crimes because their thinking rationalizes, justifies, and excuses their behavior. Criminal behavior is the result of erroneous thinking. The "criminal thinking" component is the therapeutic heart of the program. It is examined and addressed in all group and individual sessions and activities.

The program model avoids causation issues. Criminal acts are acts of choice. Each client in the program made individual choices to get where he or she is. The choice of whether to benefit from the program is the client's alone, too. The client is asked to take responsibility for his or her thinking, and the optimum opportunity for success in the program requires that the client be held accountable for all of his or her actions, past, present, and future.

Thus, for a client to take responsibility for his or her thinking and behavior, it is important for that client to admit that he or she is a criminal. The word "criminal" is used the same as the word "alcoholic." The alcoholic must admit and accept that he or she is an alcoholic in order to begin recovery. We believe the criminal must also admit and accept the fact that he or she is a criminal in order to begin recovery.

Dual Track

As the program developed, it was clear that a dual track, not envisioned in the grant application, was necessary. There were many clients who were working or going to school in the daytime. For them to participate in treatment, an evening track was therefore necessary. The program is now open from 7:00 a.m. to 11:00 p.m. Monday through Friday. This allows a day reporting/ day treatment program as envisioned by the grant and also the ability to accommodate clients in an evening program. Thus we have parallel programs, one for day clients and one for evening clients. A benefit of parallel programs is that it allows clients from each track to make up sessions in the other track. All in all, the program seems to be strengthened by the parallel tracks.

Therapeutic Community

The program is structured in an attempt to develop an outpatient therapeutic community that provides a variety of opportunities for practicing personal growth and change, including both individual and group settings. The therapeutic community (TC) can be distinguished from other major drug treatment settings in two basic ways. First, the primary "therapist" and teacher in the TC is the group of people in treatment itself, including peers and staff, who as role models of successful personal change, serve as guides in the recovery process. Second, unlike other programs, the TC offers a more systematic approach to achieve its main objectives. In the case of the Consortium, this objective is to help clients stop using alcohol and drugs, and to stop committing crimes and hurting people.

A therapeutic community is a positive environment where people who have similar problems, such as criminality and alcohol and drug abuse, live and work together to better their lives. The structure of such a community is set up like a large family. Staff and all its service providers represent the parent or authority figures. The program follows a chain of command, in which all participants strive to earn better privileges, jobs, and status within the community and its level system. In order to demonstrate positive growth and change, the resident moves up the ladder or chain of command by complying with the rules, attending on a consistent basis, participating in all program activities and doing any and all current jobs well. Peers and staff work together to help all clients achieve these objectives. This may include clients addressing issues with clients in groups and other sessions to hold one another accountable for these goals on a community and on an individual basis. The new program format was initiated on February 27, 1995.

Community Training

Prior to the initiation of the program, a 2-day training, "Treatment Perspectives on Criminal Personalities," was held. All Consortium staff and 57 people from mental health, alcohol and drug programs, the Oregon Institute of Technology College, Parole/Probation, the jail, the medical community, Klamath Tribal Health, and other organizations attended. The training provided, for the first time, a clear definition of how the program was to work. It also gave staff and the other area providers a clear picture of the difference between prosocial and antisocial treatment modalities.

Removing Barriers To Treatment

The program removes as many barriers to treatment as possible. Clients are often released from jail without adequate housing, utilities, food resources, or clothing. They sometimes come to treatment with medical problems and prescriptions that they need to fill. Arranging affordable and adequate child care is often difficult for this clientele. Clients often can only find housing so far away as to make walking impossible, and most have had their driver's licenses revoked, which creates transportation problems. These social and financial circumstances create barriers to treatment. A client benefit fund was created to provide limited term financial assistance to clients who face these barriers when entering treatment. Programs that are designed to be an enhancement to treatment have been developed to address the clients' housing, clothing, transportation, child care, and medical needs.

The Consortium believes that proper diet is important to the treatment process and recognizes that clients may not always have food. Accordingly, the Consortium developed a program to provide food at the treatment center. Clients are provided with breakfast, lunch, an evening meal, and snacks.

Parole Officer

A parole/probation officer was hired by the Klamath County Community Corrections Department using State dollars and the dollars in the Consortium grant budget authorized for a parole/probation officer. The officer is assigned to the Consortium. This allows the project to have the officer full time and dedicate the officer's time to the clients initially admitted into the Consortium. The officer tracks the client, makes home visits, administers sanctions, etc. The initial few weeks of treatment are critical to engaging and retaining the correctional client. The officer's assistance enhances these first weeks and the delivery of service by the project. With the parole officer and a solid relationship with Parole and Probation, client participation and accountability have risen dramatically. The parole officer allows quicker enforcement of sanctions against clients for noncompliance. Clients receive the message that they will be held accountable for their actions. Without the immediate sanctions, an outpatient program for chronic nonincarcerated repeat offenders is impractical.

Linkages

The program has actively attempted to establish or improve community linkages with organizations such as Partnership for Drug Free Klamath County, Klamath County Corrections, Klamath County Court system, and other AOD treatment providers. It is represented at several statewide organizations (Oregon Institute for Addiction Studies, Northwest Frontier Addiction Training Centerùa CSAT funded project, and Drug Abuse Program Directors Association of Oregon). The program has membership in local committees pursuing the possibility of bringing a drug court program to Klamath County, in helping to reestablish a detoxification center coupled with a sobering station, and in determining the future direction of corrections services in Klamath County.

Evaluation Findings

Data Collection System

The Addiction Severity Index (ASI) was chosen as the data collection instrument for the project. It is a 161-item multidimensional clinical and research instrument for diagnostic evaluation and for assessment of change in client status and treatment outcome. It assesses seven life problems areas. They are: (1) medical status, (2) employment/support status, (3) drug/alcohol use, (4) legal status, (5) family history and relationships, (6) social relationships, and (7) psychiatric status.

Computer software in the form of the Easy-ASI and Easy-Track was obtained from QuickStart Systems, Inc. to analyze data produced by the ASI. This software allows compilation of more than 400 reports, completion of the quarterly report, evaluation of the project, pre/post evaluations, and a 5-page evaluation narrative on each client.

The software has been enhanced by our administrative supervisor. The reporting functions of the Easy-Track and Easy-ASI have been modified to print data reports (demographics, client status, etc.) specific to the needs of our agency, as well as adding several "user definable" fields to help capture other data relevant to our agency. Another enhancement has been the utilization of the dBase IV database package in tandem with the Easy Track/ASI software. Through the dBase software, we track individual client activities while in treatment, and group data (number of clients attending, average attendance across quarter, week, and month, etc.).

Evaluation Procedures and Studies

Program staff meet weekly with a member of the evaluation team. The evaluation team works closely with the project to determine the most appropriate data to be collected to ensure that the goals and objective of the project are being met as well as being sensitive to additional areas that could properly be evaluated by the work this project is accomplishing.

Several evaluative studies have been accomplished during the first 2 years of the project. They include:

• A client profile
• A community survey
• Arrest data
• Program performance data

We will detail only three of these. Because of the relatively short duration of the project, the numbers are small in most of the samples. However, they seem to indicate that the program is making an impact on reducing the arrest rates of the clients.

We examined client profiles of all 112 clients admitted during the second year of the program's operation on 18 variables. ASIs were first administered June 1, 1995, and thus were only given to the last 62 clients admitted to the program. Data on these clients are presented in table 1.

Table 1. Client characteristics

Variable
Drug	60% amphetamine
Program	40% day
Marital status	11% m, 536% ds
Work	32% f, 26% p, 36% u
Race	87% white
Gender	69% male
Age	31.4
Education (mos.)	135.3
Prior alcohol treatment (no.)	2.43
Prior drug treatment (no.)	2.59
Income/month	$243.11
ASI scores
Alcohol severity	5.40
Drug severity	7.55
Employment severity	5.35
Family severity	5.08
Legal severity	6.31
Medical severity	1.79
Psychiatric severity	3.46

m=married; ds=divorced/single; f=full time; p=part time; u=unemployed.

Consortium clients are mostly white, male amphetamine abusers. Although most clients are male, the Consortium admits a higher percentage of women than exists in the target population. Clients average slightly over an 11th grade education and are rarely married. Amphetamine is often manufactured locally; Klamath Falls is a manufacturing center for it. The high levels of amphetamine abuse suggest that Consortium clients have been involved in drug trade. This conjecture is supported by the low legal monthly earnings of clients.

We studied arrest records of all 47 Consortium clients who had been in the program for at least 3 months as of December 1, 1995. We began 2 years before program entry, and followed them from that point until December 1, 1995. In the 2 years prior to program entry, arrest rates increased steadily. For all 47 clients, arrest rates were down 33 percent from what they were before program entry. Arrest rates of clients in the program 9 months or more fell 88 percent from what they were in the 3 months before program entry. The reduced arrest rate was not caused by attrition of clients with the most severe alcohol/substance abuse problems. Over two-thirds of clients had lower arrest rates after they entered the program than before they entered it. The reductions in arrest rates increased the longer the clients were in the program. These results suggest that the Consortium model is effective on an outpatient basis. Data on changes in arrest rates are presented in table 2 and figure 1.

Table 2. Arrest rates

	3-5 mo. Tx	6-8 mo. Tx	9 mo. + Tx
No. of clients	23	10	14
Total Klamath Falls arrests at admission	11.08	12.1	10.86
Arrest rate before entry	1.34	1.57	1.41
Arrest rate after entry	1.14	1.53	0.55
Percentage of decrease in arrest rate	15%	3%	61%
Percentage of clients with lower rate	43%	80%	86%

We also conducted a study on the extent to which the first 18 clients, in the program for 6 months, had met goals for individual clients established in the grant. These goals are:

__ Goal/Objective 5: 50 percent of enrolled clients will successfully complete treatment as indicated by completing two-thirds of their treatment goals identified in treatment planning during year 3.
__ Goal/Objective 6: In year 3, 55 percent of clients unemployed at the beginning of treatment will improve their employability or be employed at the successful completion of treatment.
__ Goal/Objective 7: 75 percent of clients will have attended a minimum of five self-help groups in the quarter prior to successful completion of treatment.
__ Goal/Objective 8: 85 percent of individuals remaining in treatment during year 3 for a minimum of 6 months will reduce their rate of arrest for new criminal activity during treatment. New criminal activity does not include arrests for probation/ parole violations or noncompliance with the treatment program, sanctions for relapse, or dirty urine.
__ Goal/Objective 9: During year 3, 60 percent of clients will be abstinent from substances prohibited by the program as indicated by random alcohol and/or drug testing for the 30-day period prior to the termination of their probation or parole status and/or successful completion of treatment.
__ Goal/Objective 10: 60 percent of clients remaining in treatment for a minimum of 6 months will report progress toward meeting the goals identified in their initial assessment/evaluation and/or treatment planning.

Although the numbers in this study are small, the results are encouraging. All six goals were exceeded by percentages ranging from 8 percent to 34 percent (see figure 2).

Recommendations

After considering our experiences we would like to make the following recommendations to criminal justice and treatment provider personnel in rural areas.

First, for progress in treating criminal substance abusers, the first step is often simply collection of data documenting the extent of the problem. Without the efforts of the jail nurse, Jacki Hoffman, in this area, we never would have made an impact. Efforts to obtain funds to make progress must often begin with data collection.

Second, in small rural towns sufficient expertise to make progress exists, but it is likely to be split among criminal justice and substance abuse providers working for many different organizations. For us, and very likely for many rural areas, only coalitions that bring together these organizations are likely to have the resources to succeed. Such coalitions can also succeed in many other rural areas.

Third, sufficient cooperation can be achieved among these diverse organizations to make progress if members of these organizations are willing to devote the time (for us it was several years) and put aside short-term personal goals. While this was difficult for us, we all feel the effort was well worthwhile. You will also.

Fourth, chronic repeat offenders require an intensive, consistent, antisocial treatment model to be successful. It was difficult for many treatment providers to consider our antisocial model, and difficult to staff it in a small town. Nonetheless, with sufficient patience and attention to selling the need for this approach, we were able to do it. You will be also.

Fifth, the evaluation MIS and the evaluation as a whole required close contact between evaluation staff and program people. For example, when we tried implementing the computer system using a contractor from out of town, the system did not work. After we went to a local contractor, the system caught up rapidly. The local contractor was simply able to be around more when he needed to be. Our evaluation worked best when the evaluation staff was part of the treatment team and the treatment team was part of the evaluation staff.

Sixth, a parole officer assigned to the program is essential to ensure that sanctions are applied consistently and immediately.

References

Bush, J.M., and Bilodeau, B. Options: A Cognitive Change Program. Washington, DC: U.S. Navy and the National Institute of Corrections, U.S. Department of Justice, 1993.

The Hazelden Foundation. Design for Living (The Hazelden Substance Abuse Curriculum for Offenders). Center City, MN: The Hazelden Foundation, 1992.

Sharp, B.D., and Beam, K.J. Treatment perspectives on criminal personalities in a rural setting. In: Center for Substance Abuse Treatment. Treating Alcohol and Other Drug Abusers in Rural And Frontier Areas. Technical Assistance Publication (TAP) Series, No. 17. DHHS Pub. No. (SMA) 95-3054. Rockville, MD: Center for Substance Abuse Treatment, 1995. pp. 93-102.

Yochelson, S., and Samenow, S.E. The Criminal Personality: A Profile for Change. Vol. 1. Northvale, NJ: Jason Aronson, 1976.

Yochelson, S., and Samenow, S.E. The Criminal Personality: The Change Process. Vol. 2. Northvale, NJ: Jason Aronson, 1977.

Yochelson, S., and Samenow, S.E. The Criminal Personality: The Drug User. Vol. 3. Northvale, NJ: Jason Aronson, 1986.

Continuum of Services for Offenders in South Dakota

Catherine E. Bartels, M.Ed., CCDC III
Administrator, Corrections Substance Abuse Program
South Dakota Department of Human Services
Division of Alcohol and Drug Abuse
Pierre, South Dakota

Abstract The South Dakota Corrections Substance Abuse Program, which began in 1988, has grown and evolved to include a full array of chemical dependency services at all adult and juvenile corrections institutions plus referral and collaboration with community-based alcohol/drug agencies for parolees. The program content for the institutional chemical dependency program is focused on the link between criminal behavior and chemical use, and the program format is specific to offenders. This program utilizes the cognitive ôCriminal Thought Processö approach in combination with 12-step therapeutic materials. Chemical dependency services in the three State adult correctional facilities include chemical dependency assessments on all incoming inmates based on DSM-IV criteria; pretreatment services and intensive chemical dependency treatment for those adults who have a chemical dependency diagnosis; relapse prevention; individual counseling; Alcoholics Anonymous and Narcotics Anonymous (AA/NA) opportunities; crisis intervention; referral to community-based programs; and program evaluation and outcome measures. Chemical dependency services provided in the three State juvenile correctional facilities include all of those listed above for adult programs plus prevention education groups.

In 1988, the South Dakota Department of Corrections determined through the use of chemical dependency assessments conducted with adult inmates, and reviews of adult and juvenile criminal histories, that at least 70 percent of the juveniles and 80 percent of the adults in Department of Corrections facilities had alcohol and other drug problems that were not being addressed. The decision was made by the Department of Corrections to apply to the South Dakota Attorney General's Task Force on Drugs for funding for chemical dependency programming in correctional facilities under the State and Local Law Enforcement Assistance Programs Anti-Drug Abuse Act of 1988. The application for funding was approved, and the program began in 1988.

Since the program began, it has expanded and evolved to provide a continuum of chemical dependency services to adult and juvenile offenders while they are incarcerated and while they are supervised in communities after institutional release. The institutional chemical dependency units, which are all located in South Dakota Department of Corrections facilities, are State-accredited programs staffed by certified chemical dependency counselors who are employees of the State.

During State Fiscal Year 1995, a total of 925 adults and 273 juveniles received chemical dependency assessments in South Dakota correctional facilities. Of these, about 80 percent of the adults and 68 percent of the juveniles had a diagnosis of substance abuse, using DSM-IV criteria. During this same time frame, 428 adults and 154 adolescents completed chemical dependency treatment in correctional institutions. Those who complete these treatment programs are referred to community-based agencies when they exit the institutions.

The three South Dakota institutional chemical dependency programs for adults are located at the South Dakota State Penitentiary in Sioux Falls, the Springfield State Prison, and the Yankton Trusty Unit. The juvenile institutional chemical dependency programs are located at the State Training School in Plankinton, the Youth Forestry Camp in Custer State Park, and the Lamont Youth Development Center located in Redfield. A total of 21 chemical dependency counselors provide a full range of services in these facilities.

Linkages between the institutional programs and community-based agencies and between State entities have been established through interagency agreements and memoranda of understanding so that offenders may be served throughout their involvement with the criminal justice system.

Purpose

The mission of the Corrections Substance Abuse Program is to provide a continuum of quality chemical dependency services to adult and juvenile offenders. This will give them the knowledge and tools to live chemically free lifestyles, which will enhance their opportunity for successful community reintegration following release from custody and/or supervision.

While the programs have changed in many aspects since 1988, the primary goal of providing the appropriate level of service based on detailed assessment data and diagnoses has always been a foremost concern. Another basic tenet of the program has been the recognized need for integration and acceptance of chemical dependency services within each institution. The level of program integration and acceptance is different in each of the facilities based on the level of institutional security needs, the level of other programming available, the institutional organizational hierarchies that are in place, and the physical locations at each facility for substance abuse program provision.

Those adults and juveniles who have received chemical dependency treatment services while they are incarcerated are referred to community-based agencies for continuing care and related services upon institutional release. Adults on parole are supervised by Parole Agents who are employees of the Department of Corrections. Juveniles on aftercare are supervised by Court Services Officers who are employees of the Unified Judicial System. Employees of the institutional chemical dependency programs, Parole Services, Court Services, community-based agencies, and the Division of Alcohol and Drug Abuse have a great deal of contact with each other in order to provide an appropriate level of continuing services to offenders after they leave correctional facilities.

Methods

The following section will describe the methods used to screen, assess, and provide appropriate service delivery to the juveniles and adults in Department of Corrections facilities.

Assessment

A variety of validated screening and assessment tools for juveniles and adults are available and used during the assessment process. Each adult and juvenile inmate completes a battery of written screening and assessment tools and a structured interview that delineates the effects of alcohol and drugs on nine critical life areas. Diagnoses are based on the DSM-IV criteria for substance abuse related disorders. The level and type of institutional services received are based on the results of the assessment, program availability, and length of sentences or parole dates.

Programming

All of the chemical dependency counselors in the Corrections Substance Abuse Program are trained in the cognitive theory based Criminal Thought Process Model, which is integrated with the 12-step based therapeutic model. Abstinence from all mood-altering chemicals and abstinence from criminal behavior are the two key programmatic goals. Issues related to personal responsibility and accountability are at the forefront of programming along with education about the progression of the disease of chemical dependency and the effects of chemical use on self and others.

Approximately 20 percent of the adults and juveniles who receive chemical dependency services in the correctional facilities are Native American. While separate programming for Native Americans is not offered, all of the counselors are trained in issues related to Native American cultural and spiritual values. Most of the counselors have received training in the Red Road approach to chemical dependency treatment for Native Americans, and sweat lodges, pow-wows, and other self-help groups specifically for Native Americans are available at the correctional facilities.

The services offered at each of the Department of Corrections institutional chemical dependency program are described next.

Adult Corrections Substance Abuse Program

South Dakota State Penitentiary

All male adults sentenced to the Department of Corrections receive a chemical dependency assessment as well as medical, mental health, educational, and vocational assessments at the Orientation and Induction Unit of this facility. The inmates who receive chemical dependency treatment services at the penitentiary must be at the minimum custody level before receiving treatment.

All chemical dependency programming at this all-male, multicustody level facility is provided at the West Farm Unit, which is located 12 miles from Sioux Falls. The specific chemical dependency services provided at this unit include pretreatment services and treatment. The inmates who receive these services are housed together at the West Farm and are separated from other inmates. Three chemical dependency counselors provide the services at the West Farm.

The pretreatment program consists of a 24-hour, 4-week educational and group treatment format. Subjects covered include alcohol and drug effects information, the use of criminal thinking errors and tactics to avoid responsibility, and the development of written chemical use and criminal behavior histories. The goal of this program is to help inmates prepare for treatment by decreasing denial and resistance and increasing self-knowledge about the effects of chemical use and criminal activity on their lives.

The intensive treatment program at this facility consists of 72 hours of programming over 6 weeks. The format includes didactic presentations, group therapy, and individual therapy, combined with Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) attendance. The last 2 weeks of programming are basically devoted to relapse prevention education and the development of individual relapse prevention and aftercare plans.

Springfield State Prison

Springfield State Prison is a medium security coed prison with an emphasis on vocational and chemical dependency programming. The inmates who are involved in chemical dependency programming are housed separately from the general population. Seven chemical dependency counselors provide the treatment services at this unit. The men at this prison receive chemical dependency assessments at the State Penitentiary prior to transfer to Springfield, and the women receive their assessments at Springfield.

A phased treatment program modality is in place at this facility. All inmates with a chemical dependency diagnosis attend a 100-hour, 4-week, basic treatment program that consists of didactic presentations, group therapy, and individual therapy combined with AA/NA attendance. Following completion of this phase, inmates may enter one of three programs depending on an objective assessment of progress during the first phase. Some inmates move directly to the continuing care program, but most enter either the Advanced Treatment or the New Beginnings group. The Advanced Treatment group is designed for those who made progress during the first phase, and the New Beginnings group is for those inmates who are more entrenched in chemical use and criminal thinking.

Yankton Trusty Unit

Chemical dependency pretreatment services and treatment similar to that offered at the South Dakota State Penitentiary are currently available at this minimum security unit. Plans for a 40-bed therapeutic community are developing with a start date scheduled for November 1996. Currently, two counselors provide the chemical dependency services at this unit, and when the new programming begins, another counselor will be added.

Aftercare

All adults who complete treatment at one of the above institutional chemical dependency programs are referred to community-based chemical dependency programs following institutional releases. Funding has been established for community-based chemical dependency aftercare programming for parolees. The community-based services for parolees may include transitional care, custodial care, aftercare groups, family and individual counseling, and case management services in which the parolees, the service providers, and the Parole Agents establish the parole chemical dependency services plan.

Juvenile Corrections Substance Abuse Program

State Training School

A full range of chemical dependency services are available at this 105-bed coed facility for adjudicated juveniles. Five chemical dependency counselors provide the services, which are integrated and coordinated with all other program areas and services at this institution. The institutional therapeutic approach is the Positive Peer Culture, which works well with the model that has been developed for chemical dependency services delivery. The approach integrates the cognitive/behavioral Criminal Thought Process model with a 12-step based practical and philosophical program.

Each new juvenile admitted to this facility has complete chemical dependency assessment, and the services that are provided are based on the results of the assessment. Those who do not have a DSM-IV chemical abuse or dependency diagnosis are referred to the Prevention Education Program. Those who do have a dependency or abuse diagnosis are referred to the Pre-Treatment Program, where issues regarding denial, the effects of chemical use, and criminal activity are addressed. After completing the pretreatment component, these juveniles are referred to the Adolescent Intensive Treatment Program. This 70-hour program consists of educational presentations, group therapy, individual counseling, and AA/NA attendance. Those who complete the treatment program are then referred to the Continuing Care Program, where individual relapse prevention and aftercare plans are developed.

Youth Forestry Camp

This 54-bed all-male correctional facility is located within the Custer State Park. The boys who are in this facility are involved in park maintenance and fire suppression activities as well as school and therapeutic programs. The chemical dependency program components at this facility are very similar to those at the State Training School. Two chemical dependency counselors provide assessments, prevention education, pretreatment services, intensive treatment, and continuing care.

Lamont Youth Development Center

The Lamont Youth Development Center is a 24-bed all-female correctional facility located in Redfield, South Dakota. This program for girls has a full range of chemical dependency services that are similar to those offered at the State Training School and the Youth Forestry Camp. Because this is an all-female facility, additional program activities are provided that are more pertinent to females such as abuse issues, eating disorders and self-image, and co-dependency.

Aftercare

All juveniles who complete the treatment program at one of the three juvenile correctional facilities are referred to community-based alcohol and other drug (AOD) programs for aftercare services. The juveniles are supervised by Court Services Officers following institutional release.

Program Evaluation and Followup

Data Collection

Assessment data for all persons, both youth and adults, who are clients of one of the Corrections Substance Abuse Programs, are collected by three questionnaires. A client's assessment questionnaire, administered at the completion of the treatment program, is used to obtain the client's perception of the usefulness of various aspects of the program. The counselors' assessment of the client's progress is also completed at the conclusion of the treatment program. The records are fairly complete for the client and counselor assessments. The third form administered is a followup form designed to measure client outcomes in the areas of arrests, substance use, work status, educational program attendance, and other progress while on supervision.

The followup information for the youths comes from Court Services Officers after 3 months of probation following discharge from one of the three juvenile corrections programs. Followup information is available on about three-quarters of the youths.

Followup information for adult clients is obtained from parole

officers who supervise former clients of the institutional treatment programs who have been paroled. Information is available on approximately one-half of the former inmates who have completed a substance abuse treatment program while incarcerated. Information is not available on former clients who are directly discharged from the institutions and not placed on parole or who are paroled to other States.

Summary of Basic Findings

The clients give very high ratings to the programs. The clients are especially impressed with the counselors, the group and individual counseling, and the overall program. Overall, about 90 percent of the clients rated important aspects of the program as good or excellent. About 96 percent of the clients who completed the treatment programs indicated that they would recommend the program to other people.

Juvenile Clients

After 3 months of supervision, the youths were found to have an abstinence rate for alcohol of 61.7 percent. The abstinence rate for all substance use of those from the juvenile program was a very respectable 58.9 percent. Alcohol is the main substance of use and abuse of young and old in South Dakota.

About one-half (49 percent) of the juveniles with poor relationships with persons in their homes were arrested while they were on probation, while only 10.2 percent with good relationships were arrested while on probation. Nearly one-half (46.7 percent) of the juveniles with poor progress in academic areas were arrested while they were on probation, while only 6.2 percent with good progress were arrested while they were on probation. More than one-half (52.4 percent) of the juveniles with poor progress in vocational areas were arrested while they were on probation, while only 6.1 percent with good vocational progress were arrested while on probation.

Adult Clients

After an average of 13.5 months of parole supervision, the former adult clients had an abstinence rate of 58.2 percent for alcohol. The abstinence rate for all substance use of those from the adult programs was 57.7 percent.

Other Findings

Those who attended community-based aftercare and AA/NA were much more likely to have successful outcomes (abstinent, not arrested, did not violate parole, did not abscond) than those who did not take part in these services.

Those with higher levels of education were less likely to be using substances. In general, people with favorable ratings of the institutional treatment program were less likely to violate parole or to be using chemicals following institutional release. Other results demonstrated that those who were working were less likely to violate parole, be arrested, abscond from parole, or use mood-altering chemicals.

Problems Encountered and Solutions

Program Implementation

From the inception of the program, the Secretary of the Department of Corrections was very supportive of chemical dependency services in the correctional institutions. The Secretary fought for the creation of new chemical dependency counselor positions in the department, and she directed that the programs be implemented within the adult and juvenile corrections institutions. In order to decrease administrative functions and consolidate fiscal and programmatic efforts, the employees and the funding for the Corrections Substances Abuse Program moved from the Department of Corrections to the Department of Human Services, Division of Alcohol and Drug Abuse, in August 1995. This decision was made with the approval of the Governor and the Secretaries of the Departments of Human Services and Corrections. This illustrates the point that the success of programming efforts in correctional facilities must have the support of key decisionmakers in order to develop and maintain viability.

Early in the program development and implementation process, a few of the institutional administrators and security staff were not supportive of chemical dependency services. Additionally, institutional educational and vocational program staff were concerned that their time and programming efforts with inmates would be decreased because of the new chemical dependency programming. There was a period of tension, adjustment, and gradual accommodation in all of the institutions as the programs became operational.

Much of the opposition to chemical dependency services diminished as the institutional program and security staff began to realize that inmates were easier to work with and more motivated after they had completed chemical dependency programming. Chemical dependency counselors now sit on inmate classification boards and disciplinary hearing teams, and provide information to the Parole Board. They also provide preservice training to all new institutional staff on the criminal thought process model and chemical dependency issues so that all employees are familiar with what the program is attempting to accomplish. Inmates who have chemical dependency treatment needs do not move through the prison system until they complete programming, so all employees are working toward assisting inmates achieve the needed level of programming.

Another reason for gradual acceptance of the chemical dependency staff and programming efforts is that a concerted effort has been made to cooperate with other programs and institutional areas such as security, food services, and medical units. The chemical dependency programs have always operated under the caveat that institutional security is a priority and that programming must conform to security needs.

In the juvenile institutions, where there is a greater overall therapeutic emphasis than in the adult institutions, the chemical dependency units are integrated into the facility-wide programming. The chemical dependency counselors are part of the &oc