Understanding Substance Use Treatment Outcomes for American Indian and Alaska Native Individuals with Legal Involvement

Background and Purpose: American Indian and Alaska Native (AI/AN) individuals with a history of legal involvement face multifaceted challenges intersecting historical trauma, systemic marginalization, and contemporary social inequities. Like others, AI/AN individuals intersect at different touchpoints with the legal system and have disproportionate negative outcomes at each point when compared to other racial groups. Specific to individual-level factors that intersect with legal involvement for AI/AN individuals, rates of substance misuse and substance use disorders are high among this population and are often comorbid with mental health disorders. Thus, treating substance misuse has the potential to disrupt an individual's involvement in the legal system.

There remains a gap in understanding factors that may be related to substance use treatment outcomes for AI/AN individuals with legal-involvement. The present study aims to examine differences in treatment outcomes by type of treatment referral, primary substance of use and mental health comorbidity. Specifically, the source of treatment referral is important, particularly for legal system referrals, as legal involvement is linked with access and outcome barriers for many populations.

Methods: Study data came from the 2015-2019 Treatment Episode Dataset-Discharges (TEDS-D), which contains data on treatment discharges from state-funded substance use treatment centers in the U.S. The analytic sample included 13,287 Native adults referred to outpatient substance use treatment from legal system agencies. Study outcomes were reduced substance use at discharge compared to admission and successful treatment completion. Key predictors included the type of legal system referral, primary substance of use, and mental health comorbidity. Multivariable logistic regression was used to examine associations of key predictors with study outcomes, adjusting for sex, age, education, employment status, housing status, treatment history, and self-help group attendance. Results are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI).

Results: Multivariable analyses results showed that compared to those referred from courts or diversionary programs, those referred from probation or parole (AOR = 1.82, 95% CI = 1.66-2.00) and from prison (AOR = 2.08, 95% CI = 1.65-2.62) had higher odds of reduced substance use. Mental health comorbidity, opioid use, and methamphetamine use also were linked with increased likelihood of reduced substance use. Regarding treatment completion, probation or parole referrals had lower odds of completing treatment (AOR = 0.64, 95% CI = 0.59-0.70), while prison referrals had higher odds of completing treatment (AOR = 1.40, 95% CI = 1.16-1.68) than court or diversionary program referrals. Mental health comorbidity was associated with a higher likelihood of completing treatment. Conversely, opioid and stimulant use were associated with lower odds of treatment completion.

Conclusions and Implications: The study’s findings highlight significant differences in substance use reduction and treatment completion outcomes among individual's referred from various legal settings. Moreover, given the variation in outcomes based on referral sources, interventions should be tailored to address the specific needs and circumstances of individuals referred from different legal settings. The association between mental health comorbidity and both substance use reduction and treatment completion underscores the importance of integrating mental health services into substance abuse treatment programs.