External pressure, motivation, and treatment outcome among pregnant substance-using women.

The weight of evidence suggests that legal pressure to enter treatment facilitates retention. However, the extent to which such mandates (a) influence actual levels of substance use, or (b) also facilitate retention among pregnant women, is unclear. Associations between external pressure-defined as self-reported pressure to attend treatment under threat of incarceration, loss of child custody, and/or loss of subsidized housing--and the key outcomes of retention and substance use were therefore examined in a sample of 200 pregnant women receiving community-based substance abuse treatment. The role of external pressure was examined in a series of Cox and GEE regressions, which suggested that external pressure as measured at baseline was associated with decreased risk of dropout (Hazard Ratio=.47, p=.001) and fewer drug-positive urine tests throughout treatment and 12-week follow-up (OR=.48, p=.03). These differences did not appear to be the result of baseline differences between coerced and non-coerced participants in education, legal history, the presence or absence of a substance use disorder, employment, or motivation. The present findings extend the larger literature on external pressure by demonstrating effects on drug use as well as on retention, and among pregnant women.