Substance Abuse Treatment Admissions That Were Labor Force Dropouts

In Brief
In 2008, 18.3 percent of substance abuse treatment admissions aged 18 to 64 were labor force dropouts (not employed, not looking for work, and not disabled, retired, a homemaker, a student, or an inmate of an institution) The majority of these admissions were male (66.5 percent), between the ages of 35 and 54 (55.0 percent), or had never married (58.3 percent) Over half (55.8 percent) of admissions that were labor force dropouts reported daily use of their primary substance of abuse compared with 41.2 percent of all admissions aged 18 to 64 Approximately 29.8 percent of labor force dropout admissions had a psychiatric disorder in addition to a substance use problem

Employment before or during substance abuse treatment is associated with longer stays in treatment and the likelihood of a successful treatment outcome; it also helps lessen the occurrence and severity of relapse.¹ Holding a job provides a treatment client with a legal source of income, structured use of time, and improved self-esteem, and all of these factors may reduce substance use. At treatment entry, however, many adult substance abuse treatment clients are not working, not looking for work, and report none of the commonly recognized reasons for not working (such as disability, retirement, going to school, or taking care of the home or children). Joblessness among these clients, hereafter referred to as "labor force dropouts," coupled with the financial, social, and emotional stressors associated with lack of employment, may amplify their substance abuse problems, which in turn may hinder their ability to find and maintain employment. A better understanding of the characteristics of treatment admissions that are labor force dropouts may help policy makers, program managers, and treatment service providers tailor programs that meet the needs of this population through integration of treatment with other social services.

This report uses data from the Treatment Episode Data Set (TEDS) for 2008 to examine the characteristics of substance abuse treatment admissions aged 18 to 64 who had dropped out of the labor force. TEDS includes a Minimum Data Set collected by all States and a Supplemental Data Set where individual data items are reported at the States' option. Detailed information on why an admission is not in the labor force is a Supplemental Data Set item; only data from the 41 States or jurisdictions with a response rate of 75 percent or higher on this item were used in this report.² In 2008, about 31.5 percent (446,835 admissions) of the approximately 1.4 million admissions aged 18 to 64 in these 41 States or jurisdictions were not in the labor force (i.e., were not employed and not looking for work); over half (58.2 percent) of these admissions were labor force dropouts.

The majority of substance abuse treatment admissions that were labor force dropouts were male (66.5 percent), between the ages of 35 and 54 (55.0 percent), or had never married (58.3 percent) (Table 1).³ Nearly half (47.2 percent) were non-Hispanic White, nearly one third (31.5 percent) were non-Hispanic Black, and nearly one fifth (17.7 percent) were Hispanic; less than 5 percent (3.6 percent) were of another race/ethnicity. Compared with all admissions aged 18 to 64, those that were labor force dropouts were more likely to have not graduated from high school or obtained a GED (39.6 vs. 33.6 percent).

Table 1. Percent Distribution of Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Demographic and Socioeconomic Characteristics: 2008
Demographic and Socioeconomic Characteristics	Labor Force Dropouts	All Admissions Aged 18 to 64
Total	100.0%	100.0%
Age
18 to 25	17.7%	23.6%
26 to 34	22.2%	24.9%
35 to 44	30.8%	26.4%
45 to 54	24.2%	20.3%
55 to 64	5.0%	4.8%
Race/Ethnicity
Non-Hispanic White	47.2%	61.2%
Non-Hispanic Black	31.5%	22.6%
Hispanic	17.7%	11.6%
American Indian/Alaska Native*	1.2%	2.3%
Asian/Pacific Islander	0.6%	0.7%
Other	1.7%	1.6%
Marital Status
Never Married	58.3%	58.5%
Now Married	13.7%	15.8%
Separated	6.4%	6.3%
Divorced	19.8%	17.8%
Widowed	1.8%	1.5%
Education
Less than High School	39.6%	33.6%
High School/GED	39.8%	42.5%
More than High School	20.6%	23.9%
* Alaska did not report TEDS data for 2008. Note: "Labor force dropouts" refer to admissions that were not in the labor force and did not identify themselves as a retiree, homemaker, student, inmate of an institution, or disabled person. Data for "all admissions aged 18 to 64" are based on the States and jurisdictions that reported "detailed 'not in labor force'" data. See End Notes 2 and 3. Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2008.

Almost half of admissions that were labor force dropouts (46.9 percent) had no source of income; smaller proportions reported that their principal source of income support was public assistance (14.3 percent), wages or salary (4.3 percent), disability (2.1 percent), retirement or pension (0.2 percent), or some other source (32.3 percent).⁴ Medicaid was the type of health insurance coverage most commonly reported by admissions that were labor force dropouts (19.3 percent); however, the majority of these admissions had no health insurance coverage (70.3 percent).⁵

The primary substance of abuse most commonly reported by admissions that were labor force dropouts was alcohol, followed by heroin and cocaine. Compared with all admissions aged 18 to 64, labor force dropout admissions were less likely to report alcohol as their primary substance of abuse (40.4 vs. 44.8 percent) and more likely to report primary heroin (23.4 vs. 15.1 percent) or primary cocaine (16.5 vs. 12.8 percent) (Figure 1).

Figure 1. Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Primary Substance of Abuse: 2008

Figure 1 Table. Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Primary Substance of Abuse: 2008
Treatment Admissions	Alcohol	Heroin	Cocaine	Marijuana	Non-Heroin Opiates	Stimulants	Other
Labor Force Dropouts	40.4%	23.4%	16.5%	9.4%	5.1%	2.7%	2.4%
All Admissions Aged 18 to 64	44.8%	15.1%	12.8%	13.4%	6.5%	3.6%	3.9%
Note: "Labor force dropouts" refer to admissions that were not in the labor force and did not identify themselves as a retiree, homemaker, student, inmate of an institution, or disabled person. Data for "all admissions aged 18 to 64" are based on the States and jurisdictions that reported "detailed 'not in labor force'" data. See End Note 2. Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2008.

Admissions that were labor force dropouts were more likely than all admissions aged 18 to 64 to report daily use of their primary substance (55.8 vs. 41.2 percent) and to report more than one substance of abuse at admission (66.3 vs. 54.5 percent). Labor force dropout admissions most commonly reported using the following combinations of substances: alcohol and cocaine (29.0 percent), alcohol and marijuana (19.0 percent), marijuana and cocaine (14.1 percent), and cocaine and heroin (13.8 percent) (Figure 2).

Figure 2. Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Selected Combinations of Substances: 2008

Figure 2 Table. Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Selected Combinations of Substances: 2008
Combinations of Substances	Percent
Alcohol and Cocaine	29.0%
Alcohol and Marijuana	19.0%
Marijuana and Cocaine	14.1%
Cocaine and Heroin	13.8%
Alcohol and Heroin	9.8%
Marijuana and Heroin	4.5%
Alcohol and Non-Heroin Opiates	3.4%
Alcohol and Methamphetamine	2.2%
Cocaine and Methamphetamine	1.0%
Note: "Labor force dropouts" refer to admissions that were not in the labor force and did not identify themselves as a retiree, homemaker, student, inmate of an institution, or disabled person. Admissions can report up to three substances of abuse at admission. Source: SAMHSA Treatment Episode Data Set (TEDS), 2008.

The majority of the admissions that were labor force dropouts had been in treatment at least once before (68.7 percent); nearly one fifth (17.7 percent) reported five or more prior admissions. The type of treatment services received differed between labor force dropouts and all admissions aged 18 to 64. Admissions that were labor force dropouts most commonly received detoxification and regular outpatient treatment (34.5 and 27.8 percent, respectively); in comparison, 22.4 percent of all admissions aged 18 to 64 received detoxification, and 47.7 percent received regular outpatient treatment.

The most common principal sources of referral to treatment among labor force dropouts were self-referrals (39.0 percent), alcohol or drug abuse care provider referrals (19.6 percent), and criminal justice system referrals (18.4 percent) (Figure 3). In general, the sources of referral to substance abuse treatment for these admissions were similar for males and females; however, male admissions were more likely than their female counterparts to have been self-referred (41.0 vs. 35.1 percent) and less likely to have been referred by other community sources (13.3 vs. 19.1 percent).

Figure 3. Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Referral Source: 2008

Figure 3 Table. Substance Abuse Treatment Admissions Aged 18 to 64 That Were Labor Force Dropouts, by Referral Source: 2008
Self Referral	Alcohol or Drug Abuse Care Provider	Criminal Justice System	Other Community	Other Health Care Provider	Other
39.0%	19.6%	18.4%	15.2%	7.4%	0.4%
Note: "Labor force dropouts" refer to admissions that were not in the labor force and did not identify themselves as a retiree, homemaker, student, inmate of an institution, or disabled person. Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2008.

Compared with all admissions aged 18 to 64, those that were labor force dropouts were more likely to be homeless (23.3 vs. 13.4 percent)⁶ but almost equally likely to have a co-occurring psychiatric disorder (29.8 vs. 29.2 percent).⁷

In 2007, less than one half (48.6 percent) of discharges that were labor force dropouts completed treatment, 12.9 percent were transferred for further treatment, about one quarter (25.2 percent) dropped out of treatment, and 8.8 percent were terminated from treatment by a facility.⁸ Treatment outcomes among labor force dropouts were similar to those among all discharges aged 18 to 64.

Employment has been linked to positive outcomes for substance abuse treatment clients.¹ Yet, TEDS data indicate that nearly 1 of every 7 admissions enter treatment as a labor force dropout. Many labor force dropout admissions exhibit patterns of substance abuse that may make treatment particularly challenging. For example, compared with substance abuse treatment admissions in general, these admissions are more likely to report primary abuse of heroin or cocaine, multiple substances of abuse, and daily use of their primary substance of abuse. Clients with these patterns of substance abuse may be at high risk for relapse, have complex triggers for use, or have neurological, cognitive, or other health impairments related to substance use. Labor force dropouts may also face an array of additional challenges, such as homelessness and lack of education, which further impair their ability to find and retain employment.

The substance abuse treatment system provides an opportunity not only to treat the substance abuse problems of labor force dropouts, but also to connect them with supportive services that can prepare them to enter the workforce (e.g., job skills training and employment services, housing, and mental health services). A continuum of care with a variety of integrated services may help these clients improve their chances of recovery and establish themselves as productive members of their family and community.

¹ Center for Substance Abuse Treatment. (2000). Integrating substance abuse treatment and vocational services (Treatment Improvement Protocol [TIP] Series 38, DHHS Publication No. SMA 00-3470). Rockville, MD: Substance Abuse and Mental Health Services Administration.
² Detailed "not in labor force" is a Supplemental Data Set item. The 41 States and jurisdictions in which it was reported for at least 75 percent of all admissions aged 12 or older in 2008—AR, AZ, CO, DC, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MT, NC, ND, NH, NJ, NM, NY, OH, OK, PA, PR, SC, SD, TN, TX, UT, VA, WA, WI, WV, and WY—accounted for 81 percent of all such substance abuse treatment admissions in 2008. In this report, data for Minimum Data Set items (i.e., gender, age, race/ethnicity, education, primary substance of abuse, frequency of use, and type of service at admission) for both labor force dropout admissions and "all" admissions are based on these 41 States and jurisdictions.
³ Marital status is a Supplemental Data Set item. The 37 States and jurisdictions in which both detailed "not in labor force" and marital status were reported for at least 75 percent of all admissions aged 12 or older in 2008—AR, AZ, CO, DC, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MT, NC, ND, NH, NJ, NM, OK, PA, PR, SC, SD, TN, TX, UT, WA, WV, and WY—accounted for 56 percent of all such substance abuse treatment admissions in 2008. In this report, marital status data for both labor force dropout admissions and "all" admissions are based on these 37 States and jurisdictions.
⁴ Source of income support is a Supplemental Data Set item. The 30 States and jurisdictions in which both detailed "not in labor force" and source of income support were reported for at least 75 percent of all admissions aged 12 or older in 2008—AR, CO, DC, DE, FL, HI, IA, ID, IL, KS, KY, LA, MA, ME, MN, MO, MT, ND, NH, NY, OH, PA, PR, SC, SD, TN, TX, UT, WV, WY—accounted for 61 percent of all such substance abuse treatment admissions in 2008.
⁵ Health insurance is a Supplemental Data Set item. The 30 States and jurisdictions in which both detailed "not in labor force" and health insurance were reported for at least 75 percent of all admissions aged 12 or older in 2008—AR, AZ, CO, DC, DE, HI, ID, IL, IN, KS, KY, LA, MA, MD, ME, MO, MT, ND, NH, NJ, NM, OK, PA, PR, SC, SD, TX, UT, WV, and WY—accounted for 42 percent of all such substance abuse treatment admissions in 2008.
⁶ Living arrangements is a Supplemental Data Set item. The 40 States and jurisdictions in which both detailed "not in labor force" and living arrangements were reported for at least 75 percent of all admissions aged 12 or older in 2008—AR, AZ, CO, DC, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MT, NC, ND, NH, NJ, NM, NY, OH, OK, PR, SC, SD, TN, TX, UT, VA, WA, WI, WV, and WY—accounted for 77 percent of all such substance abuse treatment admissions in 2008. In this report, living arrangements data for both labor force dropout admissions and "all" admissions are based on these 40 States and jurisdictions.
⁷ Psychiatric problem in addition to alcohol or drug problem is a Supplemental Data Set item. The 26 States and jurisdictions in which both detailed "not in labor force" and psychiatric problem in addition to alcohol or drug problem were reported for at least 75 percent of all admissions aged 12 or older in 2008—AR, CO, DE, FL, IA, ID, IL, KS, KY, LA, MD, ME, MI, MO, MT, NC, ND, NM, OH, OK, PR, SC, SD, TN, UT, and WY—accounted for 39 percent of all such substance abuse treatment admissions in 2008. In this report, co-occurring disorders data for both labor force dropout admissions and "all" admissions are based on these 26 States and jurisdictions.
⁸ Reason for discharge, transfer, or discontinuance of treatment is a Discharge Data Set item. It was analyzed for the 36 States and jurisdictions in which detailed "not in labor force," a Supplemental Data Set item, was reported for at least 75 percent of all admissions aged 12 or older in 2007—AR, AZ, CO, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MN, MO, NC, ND, NH, NJ, NY, OH, OK, OR, PR, RI, SC, SD, TN, TX, UT, VA, WA, WI, and WY; these States accounted for 76 percent of the total discharge records that could be linked to an admission or transfer record in 2007. In this report, reason for discharge data for both labor force dropout admissions and "all" admissions are based on these 36 States and jurisdictions.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (May 26, 2011). The TEDS Report: Substance Abuse Treatment Admissions That Were Labor Force Dropouts. Rockville, MD.