URJHS Volume 8

Evaluation of a Drug Court Serving Female Prescription Drug Misusers:
Relationship of Substance Use to Co-Occurring Trauma History and Symptoms

Amber Hannah
California State University, Los Angeles

M. Scott Young*
Kathleen Moore*
Louis de la Parte Florida Mental Health Institute at University of South Florida

Abstract

The present study examined the relationship between lifetime trauma, trauma symptoms, and substance use among female prescription drug misusers enrolled in a court supervised substance abuse treatment program. Participants were sixteen women enrolled in the Pinellas County Adult Drug Court WeCan outpatient rehabilitation program. Results indicated that lifetime exposure to trauma was associated with trauma symptoms, and trauma symptoms were in turn related to continued substance use. Implications for trauma-informed substance abuse treatment practices and future research are discussed.

Introduction

In recent years the number of substance users in the United States has reached epidemic proportions. In 2007 the National Survey on Drug Use and Health reported that an estimated 22.3 million adults used illicit drugs within the past year (Substance Abuse and Mental Health Services Administration [SAMSHA], 2008). This report further adumbrates the emergence of two dangerous trends. First, rates of nonmedical use of pharmaceutical drugs have exceeded that of all other drugs combined except marijuana. Second, for the first time data indicate that the incidence of prescription drug misuse is greater than the incidence of any other illicit drug use, including marijuana; there were 2.5 million persons initiating prescription drug misuse in 2007, compared to 2.1 million persons initiating marijuana use (SAMSHA, 2008). Clearly, nonmedical use of prescription drugs has become an increasingly exigent matter.

Whereas the criminal justice system has traditionally utilized punitive mechanisms (e.g., incarceration) to handle drug offenders, it is increasingly more common (because of recent changes in the law) for these individuals to be diverted from correctional facilities and treated in the community. Drug courts serve as a mechanism for handling legal cases that involve individuals with alcohol and/or drug problems. Within the U.S., roughly 3,000 drug court programs have been implemented (National Drug Court Institute [NDCI], 2008). As the number of drug court programs in the nation increases, it becomes necessary to evaluate the components and outcomes within these programs and to examine the characteristics and experiences of drug court participants. With overall drug court treatment completion rates ranging widely from 27-66 percent (Government Accountability Office, 2005), studies assessing drug courts’ effectiveness in reducing substance use and other criminal behavior have presented mixed findings. However, the research regarding the characteristics and experiences among substance users participating in drug courts shows promise for future treatment programs.

An alarming majority of individuals with alcohol or drug problems also have co-occurring mental health problems (United States Department of Health and Human Services, 2003). Furthermore, several studies have found trauma to be a prevalent mental health issue among substance users (McHugo, et al., 2005; Sacks, McKendrick, & Banks, 2008; Simons, Ducette, Kirby, Staphler, & Shipley, 2003). Considering the aforementioned modest drug court completion rates and high prevalence of trauma, clients’ trauma history and symptoms may be important factors related to successful drug court completion.

Drug Court

Drug courts are special docket courts that preside over criminal cases involving drug possession and other drug related offenses. Since their introduction in 1989, drug courts have become a popular choice within the judicial system for rehabilitating non-violent criminals with substance-related disorders. Within and between each system (i.e., juvenile, adult, and family) drug court programs differ in terms of structure and target population. Although some drug courts restrict access to minor first time offenders who present a low-risk for continued substance use and criminal involvement, other programs are less stringent and admit high-risk, high need, or even violent individuals. With regard to target population, several drug courts are gender/substance specific, meaning that they accommodate only one gender or those who use a particular substance. Although drug courts vary, all offer offenders an alternative to incarceration and seek to reduce substance use.

The drug court process is rather straightforward. It involves a drug offender, whose case has been deemed eligible for drug court, going before a judge and having his/her case and related charges reviewed. In exchange for agreeing to participate in drug treatment, at the judge’s discretion, the offender receives a reduced sentence, has the charges dropped, or has probation rescinded. Drug treatment is typically provided by a treatment agency in the offender’s community that works closely with the referring drug court. Upon entering treatment, drug court clients undergo frequent monitoring, supervision, group treatment programming, and drug testing.

Although individual studies on the effectiveness of drug courts have produced varied and conflicting findings, two meta-analytic studies support the notion that drug courts do in fact effectively reduce recidivism to substance use and criminal behavior (Lowenkamp, Holsinger, & Latessa, 2005; Wilson, Mitchell, & Mackenzie, 2006). Latimer, Morgon-Bourgon, and Chretien (2006) conducted a meta-analysis of 66 drug court programs and similarly concluded that drug courts can effectively reduce recidivism among substance abusers. Despite this, the authors also found that the average attrition rate for the programs was 45 percent. This relatively high attrition rate indicates that although studies have found these programs to be effective, approximately half of drug court clients fail to complete the program. Perhaps one of the reasons that clients fail to complete drug court is because they may also have unaddressed co-occurring mental health problems that are not addressed by treatment and impede the recovery process.

Co-Occurring Substance Use and Mental Health

Co-occurring mental health problems are common among substance users. An estimated 7 million American adults, or three percent of the United States’ population, have co-occurring mental health and substance-related disorders (U.S Department of Health and Human Services, 2003). Compared to having only one condition, the presence of co-occurring disorders is associated with a variety of poor outcomes (e.g., mental health, substance use, physical health, social). In a groundbreaking report to Congress, researchers highlighted that co-occurring mental health problems present significant barriers to receiving substance abuse treatment and that unaddressed mental health problems are the leading cause of relapse to substance use (SAMSHA, 2002). As elucidated by McHugo and colleagues (2005), “Trauma is often at the core of co-occurring problems of substance abuse and mental health,” (p. 115).

Trauma can be clinically defined as an emotionally painful or shocking experience that results in enduring aversive physical or mental effects. Trauma and co-occurring substance disorders can be toxic; research has demonstrated that the two conditions often exacerbate one another. In a recent study examining the impact of trauma on residential substance abuse treatment outcome, researchers found that women who experienced early trauma showed less improvement in psychological functioning and substance use as compared to women in treatment who had not experienced early trauma (Sacks, Kendrick, & Banks, 2008). Furthermore, Jarvis and Copeland (1997) found that, among participants with a history of trauma, those who were substance abusers had significantly higher reports of drug overdoses and related seizures, more suicide attempts, and higher somatic symptoms.

Miller (2002) suggested, “the mental health symptoms caused by trauma could stimulate the addiction compulsion.” Considering the high prevalence of trauma among substance users (McHugo et al., 2005; Sacks, McKendrick, & Banks, 2008; Simons, Ducette, Kirby, Staphler, & Shipley, 2003) and low drug court completion rates (Latimer et al., 2006), a history of trauma may complicate treatment and largely account for these low completion rates. Research has shown that substance use serves as a coping mechanism for trauma whereby substances are used to modify trauma related symptoms (Jarvis & Copeland, 1997). The present study was designed to explore this perspective. Few studies have systematically investigated and compared longitudinal data on drug court participants’ reports of trauma history, trauma symptoms, and substance use. Also, despite the severity and skyrocketing incidence of nonmedical prescription drug misuse, there is a scarcity of research on its relation to trauma. The current study sought to address this gap in the literature by examining the association between lifetime trauma exposure, recent trauma symptoms, and substance use among female prescription drug users enrolled in a drug court program. It was predicted that women who reported experiencing trauma will also report higher rates of substance use and that this increased use can be attributed to elevated levels of recent trauma symptoms.

Methods

Program

Women Empowered and Coping with Addiction to Narcotics (WeCan) is a federally funded, court supervised, substance abuse treatment program located in central Florida. The program serves non-violent females 18 years of age and older who have been mandated by the Pinellas County Adult Drug Court to seek treatment. WeCan provides outpatient treatment and targets offenders with histories of prescription drug misuse. The program utilizes an evidence-based Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT) treatment model to help clients abstain from substance use and become productive members of society. Clients attend group and individual counseling once per week for 12 weeks at one of two treatment facilities operated by WeCan. Aside from psychotherapy, other program components include case management, court appearances every 30-45 days, and weekly drug screening. Program duration is contingent upon each client’s progression in treatment.

Participants

Sixteen women who were enrolled in the outpatient WeCan substance abuse treatment program were recruited for this study. Participants were deemed eligible if they were referred for treatment by the presiding adult drug court for crimes related to prescription drugs. The common crimes for which participants were arrested were driving under the influence of prescription drugs, doctor shopping, possession of prescription drugs without a prescription, and attempting to obtain prescription drugs by fraud. Participants reported their race/ethnicity as White (93.7%) or multi-racial (Black/Latina; 6.3%). The mean age of the sample was 33.8 years (SD = 9.9; range = 19 - 55). Based on DSM-IV criteria, 62.5 percent of clients were identified as having a co-occurring mental health disorder, and 25 percent were diagnosed with some form of a traumatic stress disorder.

Measures

Global Appraisal of Individual Needs (GAIN)

The Global Appraisal of Individual Needs (GAIN) is an evidence-based biopsychosocial clinical assessment tool commonly used in behavioral health treatment settings. It integrates various measures to encompass the following core sections: Background, Substance Use, Physical Health, Risk Behaviors and Disease Prevention, Mental and Emotional Health, Environment and Living Situation, Legal Needs, and Vocational Needs. The GAIN can be used to make DSM-IV diagnoses and has demonstrated exceptional reliability and validity ( Dennis, White, Titus, & Unsicker, 2006).

Embedded within the Mental and Emotional Health section of the GAIN is the Traumatic Stress Scale (TSS). The TSS consists of 12 items that each represent a trauma symptom such as nightmares, waking up in cold sweats, being afraid to go to sleep, and feelings of guilt. Respondents answer each item with either a “yes” or “no” to indicate whether they have experienced the symptom in the last 90 days. Based on the number of items endorsed, a total score is calculated in which higher scores indicate higher levels of trauma symptomology.

Life Stressor Checklist-Revised (LSC-R)

The Life Stressor Checklist Revised (LSC-R; Wolf & Kimerling, 1997) is a 30-item self-report questionnaire that measures the degree to which the respondent has experienced traumatic or stressful life events. The questionnaire contains items that are especially sensitive to women, but can also be used with men (Norris & Hamblen, 2004). Respondents are asked questions such as “Have you ever been forced to have sex?” and provide either a “yes” or “no” answer. The tool is designed with probes so that if a particular item is endorsed, additional questions are asked about the frequency and age at which the event was experienced. The LSC-R provides a total score as well as separate scores for exposure to interpersonal abuse, exposure to child abuse, frequency of interpersonal abuse, and frequency of child abuse.

Trauma Symptoms Checklist (TSC-40)

The Trauma Symptoms Checklist (TSC-40; Elliot & Briere, 1992) is a 40-item self-report questionnaire that measures symptomatology associated with child and adult traumatic experiences. It is comprised of a six subscales (Anxiety, Depression, Dissociation, Sexual Abuse Trauma Index [SATI], Sexual Problems, and Sleep Disturbance) and a total score. Respondents report the frequency in with which they have had experienced various problems (e.g., headaches, nightmares, uncontrollable crying, and passing out) over the past two months. Items are rated on a four-point Likert scale ranging from 0 (never) to 4 (often).” Psychometric studies have found support for the reliability and validity of the TSC-40 (Elliot & Briere, 1992; Whiffen, Benazon, & Bradshaw, 1997; Zlotnick, Shea, Begin, Pearlstein, Simpson, & Costello, 1996).

Procedures

The GAIN assessment tool was used to gather baseline data from each participant upon entry to the drug court treatment program. After three months of active enrollment in the program, clients completed the GAIN a second time along with the LSC-R and TSC-40. Interviewers who had received an intensive two-day training conducted all interviews at the treatment facility either face-to-face or over the telephone. Each interview lasted approximately two hours.

Analyses

Simple descriptive statistics were used to examine basic characteristics of the sample.  Cronbach’s alphas were used to assess the internal consistency of the standardized measures. Change over time was examined using paired sample t-tests for continuous variables and McNemar Chi Square tests for categorical variables.  Pearson correlations were conducted to examine the relationship between trauma history, current trauma symptoms, and substance use. All statistical tests were two-tailed and evaluated at the .05 significance level.

Results

Psychometric Properties

The internal consistency reliability of all scales as computed by Cronbach’s alpha was acceptable. The TSC-40 total score has a reliability of .95, with subscales reliabilities ranging from .72 to.85. Reliabilities of the LSC-R (.79.) and TSS (.86) were also adequate. Evidence supporting the construct validity of the TSC-40 and TSS was provided by the positive correlation with one another (r = .50, p = .05).

Substance Use Frequency

Descriptive analyses revealed that the three drugs that participants most commonly reported using in their lifetime were: alcohol (100%); painkillers, opiates, and other analgesics (68.7%); and marijuana (68.7%). The mean number of days clients reported using any substance in the past 90 days significantly decreased from 15.4 days at baseline to 2.4 days at follow-up, t(15) = 2.74, p = .015. As shown in Table 1, the proportion of clients who reported using alcohol or drugs decreased over the first three months of drug court participation, though this reduction did not attain statistical significance; whereas 75 percent of clients reported past 90-day use of any substance at baseline, only 43.9 percent of clients reported use at follow-up, χ 2(1, N=16) = 4.15, p= .06). Similarly, rates of past 90-day prescription drug misuse also declined from 43.9 percent of clients at baseline to 12.5 percent at follow-up, χ 2(1, N=16) = 4.75, p = .13. Though these differences were not statistically significant, these preliminary findings suggest positive therapeutic trends that will likely attain statistical significance as more power is obtained by increasing sample size as more individuals enroll in the drug court program.

Table 1. Substance Use over Past 90 Days

		Total Sample (n = 16)
	Baseline	3-Month Follow-Up
Any Substance Use	75.0%	43.9%
Prescription Drug Use	43.9%	12.3%

Lifetime Trauma Exposure

The mean number of lifetime traumatic events endorsed in the LSC-R was 10.8 (SD=4.8) out of a total possible 30 points. As shown in Table 2, the most commonly reported traumatic events were having someone close die (87.5%), having serious money problems (81.3%), being involved in a serious accident (68.8%), being stalked or threatened to be killed or seriously harmed (50%), witnessing violence between family members before age 18 (50%), and being emotionally abused (43.8%).

Table 2. Lifetime History of Trauma

Most Commonly Reported Traumatic Events	Total Sample (n = 16) (n = 16)
Someone close (other than child) died	87.5%
Serious money problems	81.3%
Serious accident	68.8%
Serious physical or mental illness	68.8%
Stalked, threaten to be killed or seriously harmed	50.0%
Before age 18 witnessed physical family violence	50.0%
Emotionally abused or neglected	43.8%
Physically abused	37.5%
Miscarriage	31.3%
Forced to have sex	18.8%

Trauma Symptoms and Substance Use

At baseline 37.6 percent of participants reported that their lives had been disturbed by traumatic memories in the past 90 days, and 31.3 percent reported using substances to help forget about these memories. At follow-up 62.6 percent of participants reported being disturbed by traumatic memories, and 12.3 percent used substances to help forget about them. Mean scores for the TSC-40 (see Table 3) scales indicated that sleep disturbances (m=1.7) were the most severe trauma symptoms, followed by depression (m=0.8) and anxiety (m=0.6).

Table 3. Trauma Symptoms

Total Sample (n = 16)	Mean	Range
Trauma Symptom Checklist
Total	.64	.03-2.05
Depression	.79	.00-2.44
Anxiety	.63	.00-2.00
Dissociation	.57	.00-2.17
Sexual Abuse Trauma Index	.55	.00-2.71
Sexual Problems	.34	.00-1.75
Sleep Disturbances	1.27	.00-3.00

Correlations were run to examine the bivariate relationships between lifetime trauma, trauma symptoms, and substance use (see Table 4). Results indicated a positive relationship between lifetime trauma exposure and current trauma symptoms. Specifically, baseline levels of traumatic stress were positively correlated with lifetime exposure to interpersonal abuse (r =.61, p < .05) and frequency of child abuse (r =.60, p < .05). In turn, frequency of child abuse was also positively correlated with baseline substance use (r =.61, p < .05). Follow-up substance use was positively correlated with follow-up scores for overall traumatic stress (r =.53, p < .05) and anxiety (r =.51, p < .05). Last, memory disturbance at follow up was positively correlated with lifetime history of interpersonal abuse (r =.52, p < .05).

Table 4. Correlations between mental health and substance use measures

	Baseline
3-Month Follow-Up	Memory Disturbance	TSS		Recency AOD Use		Recency Prescription Drug Use
TSC-Total	.05	.50*		.50		.43
TSC-Anxiety	.12	.58*		.47*		.31
TSC-Sexual Abuse Trauma Index	-.01	.56*		.53*		.43
TSC-Sleep Disturbances	.10	.50*		.41		.29
LSC-R Lifetime Exposure	.20	.52*		.39		.17
LSC-R Current Exposure to Interpersonal Abuse	.28	.61*		.46		.49
LSC-R Frequency of Child Abuse	.18	*.60		.61*		.48
3-Month Follow-Up
	Memory Disturbance		TSS	Recency AOD Use	Recency Prescription Drug Use
TSC-Anxiety	.41		.50*	.51*	.14
LSC-R Current Exposure to Interpersonal Abuse	.52*		.36	-.16	-.18
Recency AOD Use	.26		.53*	1	.77**

p < .05, ** p < .01 Note. LSC-R = Lifetime Stressor Checklist; TSC = Trauma Symptom Checklist; TSS = Traumatic Stress Scale; AOD = alcohol or drug

Discussion

Overall, findings from this study indicate that WeCan has been successful in reducing substance use for more than half of the sample. As expected, lifetime exposure to traumatic events was associated with baseline trauma symptomology. Among participants who did not abstain from substance use while in treatment, substance use was related to the levels of trauma symptoms experienced. Analyses indicated that 28 percent of the variability in recent substance use was accounted for by the level of recent trauma symptoms. The association between recent trauma symptoms and substance use supported the initial hypothesis. As levels of trauma symptoms increased, so did substance use. Interestingly, upon entering treatment, 37.6 percent of participants reported having their lives disturbed by traumatic memories, and this figure increased to 62.6 percent after three months of treatment. However, the percent of participants using alcohol or drugs to forget about these memories decreased from 31.3 percent upon entering treatment to 12.3 percent after three months of active enrollment. This shift suggests that participants enrolled in the drug court treatment program developed alternative ways of dealing with traumatic memories and were no longer relying on substances such as prescription drugs. Yet, because more participants reported being increasingly bothered by traumatic memories while abstaining from substances, this issue needs to be addressed. These findings suggest that females receiving substance abuse treatment should undergo a comprehensive evaluation that assesses trauma history and presenting trauma symptoms. Service providers should utilize treatment models that address trauma symptoms like sleep disturbances, depression, and anxiety in order to reduce clients’ reliance on alcohol and drugs to cope with previous traumas. In addition, trauma informed care that addresses the underlying issue of life-disturbing memories should also be employed to achieve optimal outcomes.

Limitations

Limitations of the present study include its low sample size and the homogeneity of the participants. With the exception of one client, the sample was comprised mainly of Caucasian females; therefore, results may not generalize to males or to females from other ethnic backgrounds. Another limitation relates to the reliability of participant self-reported substance use. Although confidentiality was assured, the interviews were conducted at the treatment facility. Thus, participants may have presumed that the study interviewers were associated with the treatment program. Given the facts that clients were enrolled in court supervised treatment, and that substance use was reprimanded at the treatment facility, participants may not have been completely honest when disclosing information related to their substance use.

Acknowledgements

The present study was funded by grants received from the University of South Florida, National Science Foundation, and the National Institute of Drug Abuse. In addition, the authors would like to thank WeCan participants, Operation Par, WestCare, and Pinellas County Adult Drug Court for their involvement in this study.

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