Drug and Alcohol Dependence 87 (2007) 54–62 The effect of individual, program, and neighborhood variables on continuity of treatment among dually diagnosed individuals Gerald J. Stahler a,* , Silvana Mazzella a , Jeremy Mennis a , Sanjoy Chakravorty a , George Rengert b , Ralph Spiga c a Department of Geography and Urban Studies, 309 Gladfelter Hall, Temple University (025-27), Philadelphia, PA 19122, United States b Department of Criminal Justice, 5th Floor, Gladfelter Hall, Temple University, Philadelphia, PA 19122, United States c Department of Psychiatry and Behavioral Sciences, Temple Episcopal Campus, 3rd Floor, 100 E. Lehigh Avenue, Philadelphia, PA 19125, United States Received 30 March 2006; received in revised form 28 July 2006; accepted 31 July 2006 Abstract This study reviewed the medical charts of 271 patients diagnosed with co-morbid mental health and substance-use disorders who were discharged from a hospital acute inpatient unit to various outpatient treatment programs in Philadelphia. Geographic Information Systems (GIS) technology and logistic regression modeling were employed to investigate the effects of individual, neighborhood, and program-level variables on arrival to the first treatment appointment within 30 days of discharge. Four models are presented. The results of the study suggest that having had three or more treatment episodes prior to inpatient hospitalization, and living in a neighborhood in which temporary or transitional, and presumably, other low income housing is located, increased the likelihood of patients continuing with treatment in the community. Discharge to the preadmission address, a chief complaint of bizarre behavior, close proximity of two or more liquor and/or beer stores, a high density of narcotics anonymous (NA) and/or alcoholics anonymous (AA) meetings within the neighborhood, an axis I diagnosis of substance-induced mood disorder, and a urine drug screen positive for heroin reduced the likelihood of attending outpatient treatment. We conclude that geographic and community variables as they relate to substance abuse may add an important dimension to our understanding of patient functioning and well being in the community following inpatient treatment. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Community factors; Dually diagnosed; Geographic factors; Continuity of treatment 1. Introduction One of the most robust findings in drug treatment outcome research is that continued abstinence is highly related to length of time in treatment as well as continuity of care (Condelli and Hubbard, 1994; De Leon, 1985; Grella et al., 2000; Hser et al., 2004; Hubbard et al., 1997; Prendergast et al., 2000; Simpson, 1981). We have argued elsewhere that lack of treatment conti- nuity, or client attrition, is one of the greatest problems inter- fering with treatment effectiveness in substance abuse programs (Stahler et al., 1993). This may be particularly true when clients face transitions in treatment modality, such as when clients are discharged from residential or inpatient care to outpatient treat- ment in the community. The likelihood of relapse is often a * Corresponding author. Tel.: +1 215 204 6939; fax: +1 215 204 7833. E-mail address: jstahler@temple.edu (G.J. Stahler). function of how clients deal with the environmental triggers that may be associated with substance use in the community (Lang and Belenko, 2000; Tucker et al., 1990–1991). In recog- nition of this problem, most treatment programs incorporate some form of relapse prevention involving the identification of environmental triggers as part of the treatment regimen. Indeed, alcoholics anonymous (AA) and narcotics anonymous (NA) rec- ognize this problem by urging members to avoid the “people, places, and things,” which were initially associated with their substance use. Despite the fact that there is research and clinical evidence to suggest that the environment and environmental cues have such a strong influence on attrition and relapse (e.g., Boardman et al., 2001; Jacobson, 2004; Tucker et al., 1990–1991), very little research has focused on the neighborhood environment, both physical and social, to which recovering individuals are discharged, and how this environment relates to the continuity of care, treatment outcomes, and relapse (Jacobson, 2004). As 0376-8716/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2006.07.010