Assessing quality of substance use treatment in legal settings: lessons from United States drug courts
Background: More than 1,800 adult drug treatment courts operate in the United States, with federal funding of US$169,000,000 and substantial additional funding through state and local governments. One key component of the drug treatment court model is the linkage of participants to substance use treatment and other services in the community. Yet, even after 35 years of drug court implementation and evaluation research, treatment in the drug court setting essentially remains a “black box.” Very little is known about the quality of treatment for drug court participants, or how treatment quality is related to important drug court outcomes such as relapse and recidivism. This study seeks to develop and measure indicators of treatment quality in the drug court setting and assess its relationship to participant outcomes.
Methods: The authors reviewed the empirical literature on drug court treatment and treatment quality; existing governmental, funder, and accreditation quality standards; implementation science; and UNODC/WHO treatment quality indicators. From these sources, potential quality domains and indicators were identified and synthesized. A large urban adult drug court with multiple treatment providers was selected to operationalize and assess the impact of treatment quality on drug court participant outcomes. Drug court outcomes will be assessed with treatment quality as independent variable.
Results: We identified six key domains of treatment quality: organizational characteristics, organizational resources, collaboration and communication, screening and assessment, treatment delivery, and continuous quality improvement. In addition, we identified multiple indicators of quality within each domain and sources of data for each indicator. Data sources include administrative records, stakeholder interviews, staff surveys, and direct observations of group treatment. Quality indicators are measured at four structural levels: system, provider, program, and group. After creating a summary overall quality score for each treatment program, we will analyze the impact of treatment quality on the following participant outcomes: drug court completion, reoccurrence of substance use, and rearrest.
Conclusions: Despite their popularity in the United States and many other countries, little is known about the quality of treatment delivered to drug court participants. This study develops a comprehensive, multi-domain and multi-level set of quality indicators that opens up the “black box” of treatment and allows for a nuanced assessment of differences in treatment quality among programs. By analyzing the impact of treatment quality on drug court participant outcomes, the findings provide guidance to drug court stakeholders for assessing the quality of the treatment programs to which they refer participants and move the field toward a more structured and empirically based set of quality measures that has potential predictive validity.
