How long does it take to complete outpatient substance use disorder treatment? Disparities among Blacks, Hispanics, and Whites in the US

Afrocentric Norms and Substance Use Behaviors Among Black Young Adults

Despite not displaying higher overall rates of substance use compared to White Americans, the social consequences of substance use disorders for Black Americans, particularly among Black American men, are more damaging. Furthermore, recent data suggest an uptick in substance use-related deaths among Black Americans, raising serious concerns about a growing health disparity that warrants the need for studies to identify factors associated with prevention. For decades, Black cultural theorists have argued that Afrocentric norms are important buffers against maladaptive behaviors in Black Americans, but the association in the context of substance use is still an emerging area. The present study investigated the associations between Afrocentric norms, Afrocentric self-regard, internalized negative stereotypes, and substance use attitudes and behaviors among Black young adults. Self-report questionnaires were administered to measure internalized negative stereotypes, Afrocentric norms, Afrocentric self-regard, substance use attitudes, and substance use from a sample of Black young adults (N = 619). Favorable attitudes toward substance use were found to be positively associated with internalized negative stereotypes but were inversely associated with Afrocentric norms and Afrocentric self-regard. Similarly, substance use reports within the past 30 days were inversely associated with Afrocentric norms, but the relationship to cannabis use was non-significant. Gender differences between Black men and women were also found. Implications for social work are discussed.

Racial-ethnic disparities across substance use disorder treatment settings: Sources of treatment insurance, socioeconomic correlates and clinical features

Aim: Contrary to expectations, studies of racial-ethnic disparities in substance use disorder (SUD) treatment frequently uncover minority-majority parity in access and utilization of services. What accounts for the anomaly? To answer the question, this study explores racial-ethnic differences in the odds of utilization of SUD treatment in varied settings (e.g., the criminal justice system, private doctor's office, etc.), adjusting for sources of treatment insurance, socioeconomic correlates of treatment (e.g., employment, income, education), as well as clients' clinical features (e.g., type of substance abuse/dependence, co-morbidities, health status). Methods: Data were compiled from the National Survey of Drug Use and Health (NSDUH) dataset, 2002-2014. The sample consisted of respondents with a past year diagnosis of a substance use disorder, who also reported having received treatment (n = 6,207). Data were pooled to maximize subgroup analyses. Weight- and design- adjusted logistic regressions were use to analyze factors predicting SUD treatment source. Results: Blacks were more likely than Whites to receive treatment through the criminal justice system and Whites more likely than Blacks and Latinx to receive treatment at a doctor's office. Blacks were also more likely than Whites to receive treatment through inpatient/outpatient rehabilitation, before adjustments but not afterwards. Discussion: In this study we show that even after adjusting for mechanisms expected to shape pathways from race-ethnicity to SUD treatment sites, significant racial-ethnic disparities persist. This fills an important gap in the literature in that disparities research has not explicitly modeled racial-ethnic variation across the full range of SUD treatment sites.

Disparities in substance use treatment retention: An exploration of reasons for discharge from publicly funded treatment

Although Delaware is the seventh smallest state in the country (including Washington, D.C.) in terms of population size, it has the second highest drug overdose death rate. The Delaware Division of Substance Abuse and Mental Health has increased attention in identifying disparities in treatment outcomes. We explored reasons for discharge from publicly-funded treatment in Delaware with special attention to populations at risk for health inequities, with a focus on covariates of treatment non-completion. Using secondary data collected from publicly-funded treatment providers, we analyzed data from individuals that were admitted to substance use treatment between 2015 and 2019 and had been discharged in 2019. We did this by using logistic and multinomial regression, focusing on non-completion treatment outcomes such as failure to meet requirements, loss of contact, and treatment refusal. Clients who were Black or African American, compared to white clients, were more likely to be lost contact with, administratively discharged, or marked as failing to meet treatment requirements than having a completed treatment discharge. Women were 30% less likely than men to have "failed to meet treatment requirements" compared to completing treatment. Further investigation is needed into these patterns. While treatment quality cannot be assessed using this data, the results point to a need for closer study of disparities in treatment related to race, ethnicity, gender, employment, criminal justice involvement, and type of drug used. Treatment providers should be made aware of culturally informed care, as well as client-created goals, in order to reduce disparities in exit from treatment.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative study

Question

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders, in "real world" settings.

Goal

To determine sex disparities in non-medical opioid use (NMOU) at the end of outpatient medication-assisted treatment (MAT), using nationally representative data.

Design

Observational epidemiological study of publicly funded outpatient MAT programs in the national "Treatment episode data set-discharges" (TEDS-D) for 2019.

Participants

Persons aged ≥18 in their first treatment episode, in outpatient MAT for use of heroin or other opioids (N=11,549). The binary outcome was presence/absence of NMOU.

Results

In univariate analyses, males had significantly higher odds of NMOU, compared to females (odds ratio=1.27; Chi2 [df:1]=39.08; uncorrected p<0.0001; p=0.0041 after Bonferroni correction). A multivariable logistic regression detected a male>female odds ratio of 1.19 (95%CI=1.09-1.29; p<0.0001), adjusting for socio-demographic/clinical variables. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., at ages 18-29 and 30-39; corrected p=0.012, or if they used opioids by inhalation; corrected p=0.0041).

Conclusions

This nationally representative study indicates that males have greater odds of NMOU in their first episode of MAT, indicating more unfavorable outcomes. The study reveals specific socio-demographic and clinical variables under which this sex disparity is most prominent.

Observations of substance use treatment engagement during the period of community re-entry following residential treatment

BACKGROUND

The period of community re-entry following residential substance use treatment is associated with elevated risk for return to substance use. Although continuity of care is best practice, many individuals do not engage in follow-up treatment, struggle to engage in follow-up treatment, or continue to use substances while participating in follow-up treatment. There is a need to both characterize treatment engagement during community re-entry following residential substance use treatment as well as understand how treatment impacts substance use during this high-risk period.

METHOD

This observational study used retrospective self-report to examine treatment engagement and substance use among individuals who had exited residential substance use treatment. Participants completed a Timeline Follow-back interview reporting substance use and treatment engagement in the 30 days following residential treatment.

RESULTS

Most participants (83.1 %) reported engaging in substance use treatment following discharge. The most common treatments were Alcoholics Anonymous/Narcotics Anonymous (61.1 %), medication for addiction treatment (40 %), and outpatient therapy (29.2 %). Participants were less likely to use substances on a day in which they engaged in outpatient therapy (OR = 0.32, 95 % CI [0.12, 0.90], p = 0.030) and more likely on days they engaged in medication treatment (OR = 21.49, 95 % CI [1.46, 316.74], p = 0.025).

CONCLUSION

Findings characterize engagement in substance use treatment in the month following residential treatment. Treatment engagement was common during community re-entry; however, only outpatient therapy was found to reduce substance use during this high-risk period. Findings may inform intervention efforts during the high-risk period of community re-entry.

Evidence that personalized racial stress procedures elicit a stress response and increases alcohol craving among Black adults with alcohol use disorder: A laboratory pilot study

BACKGROUND

The objective of this study was to pilot test newly developed personalized imagery procedures to investigate the impact of racial stress on alcohol craving and emotional and physiological response in Black adults with alcohol use disorder (AUD).

METHODS

Twenty Black adults (45% women, meanage=37.05, SDage=13.19) with AUD participated in two sessions. In the first, participants described a stressful personal event involving their race and a neutral relaxing situation and these descriptions were used to develop scripts for the subsequent laboratory exposure session. The second session was an experimental provocation session in which participants reported on alcohol craving and emotional response before and after imagined exposure to stress and neutral conditions using personalized racial stress and neutral/relaxing scripts. Conditions were randomized and counterbalanced across subjects, and heart rate and blood pressure were assessed before and after each image.

RESULTS

Alcohol craving and negative emotions significantly increased, and positive emotions decreased following the racial stress script relative to the neutral/relaxing script. We found no differences in physiological response. Exploratory analyses found that increase in alcohol craving was correlated with racial identity exploration but not racial identity commitment, men reported greater reductions in anger than women in the neutral condition only, and income was correlated with fear in the racial stress condition only.

CONCLUSIONS

This study provides evidence that personalized racial stress procedures elicit a stress response and increases alcohol craving and emotional response but not physiological response among Black adults with AUD. These findings warrant replication in a larger study.

LatinX harm reduction capital, medication for opioid use disorder, and nonfatal overdose: A structural equation model analysis among people who use drugs in Massachusetts

BACKGROUND

We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we hypothesize to predict MOUD use and opioid overdose. In this study, we explored the interrelationships between ethnicity, HRCap, nonfatal overdose, and MOUD use among PWUD.

METHODS

Between 2017 and 2019, people who currently or in the past used opioids and who lived in Massachusetts completed a one-time survey on substance use history, treatment experiences, and use of harm reduction services. We fit first-order measurement constructs for positive and negative HRCap (facilitators and barriers). We used generalized structural equation models to examine the inter-relationships of the latent constructs with LatinX self-identification, past year overdose, and current use of MOUD.

RESULTS

HRCap barriers were positively associated with past-year overdose (b=2.6, p<0.05), and LatinX self-identification was inversely associated with HRCap facilitators (b=-0.49, p<0.05). There was no association between overdose in the past year and the current use of MOUD. LatinX self-identification was positively associated with last year methadone treatment (b=0.89, p<0.05) but negatively associated with last year buprenorphine treatment (b=-0.68, p<0.07). Latinx PWUD reported lower positive HRCap than white non-LatinX PWUD and had differential utilization of MOUD.

CONCLUSION

Our findings indicate that a recent overdose was not associated with the current use of MOUD, highlighting a severe gap in treatment utilization among individuals at the highest risk. The concept of HRCap and its use in the model highlight substance use treatment differences, opportunities for intervention, and empowerment.

A systematic meta-epidemiologic review on nonabstinence-inclusive interventions for substance use: inclusion of race/ethnicity and sex assigned at birth/gender

Background: Minoritized racial/ethnic and sex assigned at birth/gender groups experience disproportionate substance-related harm. Focusing on reducing substance-related harm without requiring abstinence is a promising approach.Objectives: The purpose of this meta-epidemiologic systematic review was to examine inclusion of racial/ethnic and sex assigned at birth/gender in published studies of nonabstinence-inclusive interventions for substance use.Methods: We systematically searched databases (PubMed and PsycINFO) on May 26, 2022 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Articles were eligible for inclusion if they: 1) reported in English language, 2) had a primary goal of investigating a nonabstinence-inclusive intervention to address substance use, 3) used human subjects, and 4) only included adults aged 18 or older. Two coders screened initial articles and assessed eligibility criteria of full text articles. A third consensus rater reviewed all coding discrepancies. For the remaining full-length articles, an independent rater extracted information relevant to study goalsResults: The search strategy yielded 5,759 records. 235 included articles remained. Only 73 articles (31.1%) fully reported on both racial/ethnic and sex assigned at birth/gender, and only seven articles (3.0%) reported subgroup analyses examining treatment efficacy across minoritized groups. Nine articles (3.8%) mentioned inclusion and diversity regarding both racial/ethnic and sex assigned at birth/gender in their discussion and four articles (1.7%) broadly mentioned a lack of diversity in their limitationsConclusion: Findings highlight that little is known about nonabstinence-inclusive interventions to address substance use for individuals from minoritized racial/ethnic and sex assigned at birth/gender groups.

Employment, coronavirus victimization distress, and substance use disorders among black and non-Hispanic White young adults during the COVID-19 pandemic

Substance abuse among young adults increased during the COVID-19 pandemic. Although pre-pandemic data indicate non-Hispanic White adults had higher levels of substance use disorder (SUD), Black adults suffered more serious consequences. The COVID-19 pandemic has introduced new stressors that may contribute to SUD, especially among Black young adults, including employment as essential workers, which may be related to victimization distress associated with the coronavirus (i.e., coronavirus victimization distress). The current study administered an anonymous, cross-sectional, online survey to a national sample of 132 Black and 141 non-Hispanic White adults 18 - 25 years to assess the relationship between health, economic disparities, employment, coronavirus victimization distress, and substance use during the first wave of the pandemic. Controlling for COVID-19 health risks and income, structural equation models indicated that coronavirus victimization distress fully accounted for the positive association between employment and SUD risk, and this association was more pronounced among Black young adults. Findings underscore the urgency of considering disease-related victimization in SUD interventions involving employed young adults during infectious disease pandemics.

Evaluating the Effectiveness of Take it Personal!+ in People With Mild Intellectual Disability or Borderline Intellectual Functioning and Substance Use Disorder: A Multiple Baseline Single-Case Experimental Study

Individuals with mild intellectual disabilities or borderline intellectual functioning are at increased risk to develop a substance use disorder-however, effective treatment programs adapted to this target group are scarce. This study evaluated the effectiveness of Take it Personal!+ in individuals with mild intellectual disabilities or borderline intellectual functioning and substance use disorder. Take it Personal!+ is a personalized treatment based on motivational interviewing and cognitive-behavioral therapy supported by an mHealth application. Data were collected in a nonconcurrent multiple baseline single-case experimental design across individuals with four phases (i.e., baseline, treatment, posttreatment, and follow-up). Twelve participants were randomly allocated to baseline lengths varying between 7 and 11 days. Substance use quantity was assessed during baseline, treatment, and posttreatment with a daily survey using a mobile application. Visual analysis was supported with statistical analysis of the daily surveys by calculating three effect size measures in 10 participants (two participants were excluded from this analysis due to a compliance rate below 50%). Secondary, substance use severity was assessed with standardized questionnaires at baseline, posttreatment, and follow-up and analyzed by calculating the Reliable Change Index. Based on visual analysis of the daily surveys, 10 out of 12 participants showed a decrease in mean substance use quantity from baseline to treatment and, if posttreatment data were available, to posttreatment. Statistical analysis showed an effect of Take it Personal!+ in terms of a decrease in daily substance use in 8 of 10 participants from baseline to treatment and if posttreatment data were available, also to posttreatment. In addition, data of the standardized questionnaires showed a decrease in substance use severity in 8 of 12 participants. These results support the effectiveness of Take it Personal!+ in decreasing substance use in individuals with mild intellectual disabilities or borderline intellectual functioning.

Identifying the Heterogeneity in the Association between Workforce Diversity and Retention in Opioid Treatment among Black clients

Background

This study investigates the impact of workforce diversity, specifically staff identified as Black/African American, on retention in opioid use disorder (OUD) treatment, aiming to enhance patient outcomes. Employing a novel machine learning technique known as 'causal forest,' we explore heterogeneous treatment effects on retention.

Methods

We relied on four waves of the National Drug Abuse Treatment System Survey (NDATSS), a nationally representative longitudinal dataset of treatment programs. We analyzed OUD program data from the years 2000, 2005, 2014 and 2017 (n = 627). Employing the 'causal forest' method, we analyzed the heterogeneity in the relationship between workforce diversity and retention in OUD treatment. Interviews with program directors and clinical supervisors provided the data for this study.

Results

The results reveal diversity-related variations in the association with retention across 61 out of 627 OUD treatment programs (less than 10%). These programs, associated with positive impacts of workforce diversity, were more likely private-for-profit, newer, had lower percentages of Black and Latino clients, lower staff-to-client ratios, higher proportions of staff with graduate degrees, and lower percentages of unemployed clients.

Conclusions

While workforce diversity is crucial, our findings underscore that it alone is insufficient for improving retention in addiction health services research. Programs with characteristics typically linked to positive outcomes are better positioned to maximize the benefits of a diverse workforce in client retention. This research has implications for policy and program design, guiding decisions on resource allocation and workforce diversity to enhance retention rates among Black clients with OUDs.

Exercise as Medicine for People with a Substance Use Disorder: An ACSM Call to Action Statement

ABSTRACT

Over 20 million Americans are living with a substance use disorder (SUD) and nearly 100,000 die annually from drug overdoses, with a majority involving an opioid. Many people with SUD have co-occurring chronic pain and/or a mental health disorder. Exercise is a frontline treatment for chronic pain and is an effective strategy for reducing depression and anxiety and improving overall mental health. Several studies have shown that exercise improves SUD-related outcomes including abstinence; however, there is limited large-scale randomized clinical trial evidence to inform integration of exercise into practice. In this Call to Action, we aim to raise awareness of the specific issues that should be addressed to advance exercise as medicine in people with SUD including the challenges of co-occurring chronic pain, mental illness, and cardiopulmonary health conditions. In addition, specialized training for exercise professionals and other support staff should be provided on these issues, as well as on the multiple dimensions of stigma that can impair engagement in treatment and overall recovery in people with SUD.

Intersectional disparities in outpatient alcohol treatment completion by gender and race and ethnicity

BACKGROUND

Untreated alcohol use disorder (AUD) can have negative outcomes, including premature death. Completing specialty treatment for AUD can improve economic and educational outcomes. However, there are large racial and ethnic disparities in treatment completion, and how these disparities vary intersectionally (e.g., by gender and race and ethnicity) is unknown. Recent studies suggest that not using an intersectional approach can mask important disparities. We estimated disparities in AUD nonintensive outpatient treatment completion by gender alone, race and ethnicity alone, and intersectionally in a gender-by-race-and-ethnicity model. Accurately quantifying treatment completion disparities is critical not only for understanding healthcare disparities but reducing them to advance health equity.

METHODS

Data are from SAMHSA's 2017 to 2019 Treatment Episode Dataset-Discharges for adults aged 18+ who entered nonintensive outpatient treatment primarily for alcohol (n = 559,447 episodes; 30.3% women; 63.7% White, 18.0% Black, 14.4% Hispanic/Latinx, 2.1% American Indian/Alaska Native [AIAN], 1.0% Asian/Pacific Islander). Using the rank-and-replace method, treatment completion disparities were estimated by gender, race and ethnicity, and gender-by-race-and-ethnicity due to any reason other than differences in need for treatment, consistent with the Institute of Medicine's definition of a healthcare disparity.

RESULTS

The intersectional gender-by-race-and-ethnicity model identified the widest range of disparities among all models tested. Using this model, the largest disparities were identified for minoritized women's treatment episodes. Compared to White men whose completion rate was 60.79% (95% confidence interval [CI]: 60.06, 60.98), Black, Hispanic/Latina, AIAN, and Asian-American/Pacific Islander women had treatment episode completion rates that were 12.35 (CI: 12.33, 12.37), 9.08 (CI: 9.06, 9.11), 10.27 (CI: 10.22, 10.32), and 4.87 (CI: 4.78, 4.95) percentage points lower, respectively.

CONCLUSIONS

In the United States, treatment completion rates for non-intensive outpatient alcohol treatment episodes are significantly lower for minoritized women than White men. The extent of the disparity is not apparent in univariate models, highlighting the importance of an intersectional approach to understanding disparities in the completion of non-intensive outpatient treatment for AUD.

The criminal justice system in alcohol use treatment: a nationwide analysis of racial disparities in treatment referral and completion

BACKGROUND

Alcohol use and the criminal justice (CJ) system have long been integrally connected in the United States and have both disproportionally impacted Communities of Color. Despite this connection, scholarly literature has largely focused on substance use as a whole, and little literature has examined the influence of race on CJ referral to alcohol treatment and treatment outcomes.

METHODS

A total of 749,349 cases from the treatment episodes dataset discharge were used in the current study. A series of ANOVA and logistic regression analyses were conducted to examine the impact of race on (i) likelihood of referral to alcohol treatment by the CJ system and (ii) the association between CJ referral and treatment completion.

RESULTS

Results revealed significant disparities in both who is referred to alcohol treatment by the CJ system and the association of that referral to treatment completion. Notably, American Indian/Alaska Native people were significantly more likely than people of all other races to be referred by the CJ system. However, American Indian/Alaska Native people showed the smallest association between CJ referral and treatment completion.

CONCLUSIONS

Contrary to previous literature, findings showed that referral of and positive association between CJ referral and treatment completion are not equal across people of different races. Taken together, these results highlight continued racial inequities in the role of the CJ system in alcohol treatment and the unique potential for non-CJ-related treatment to best serve people combatting alcohol use disorder.

A thematic analysis of stress, substance-cue, and neutral/relaxing events to inform approaches for improving treatment among Black adults who use substances

INTRODUCTION

To inform approaches for adapting substance use treatment for Black adults, the aim of this study was to thematically analyze the stressors, triggers for substance use, and neutral/relaxing events reported among Black adults who participated in a lab paradigm.

METHODS

The sample included 36 Black adults (mean age [years] = 37.47, SD = 7.30; 53 % male, 12 (33 %) with alcohol use disorder, 12 (33 %) with cocaine use disorder, and 12 (33 %) healthy controls). All participants provided detailed stimulus and response context information on the most stressful event they experienced in the past year, an event that involved substance use, and a neutral/relaxing event in a structured interview using a scene development questionnaire, and this information was utilized to generate a personalized imagery script for each event using standardized procedures. Thematic analyses identified the key themes reported within scripts.

RESULTS

Consistent with a prior thematic analysis on a majority White sample, we found the following themes for the stress scripts: Relational (Violation, Loss, Parenting, Betrayal, Isolation vs. support), Environmental (Housing, Legal), and Achievement (Employment, Role in household). However, our analyses also resulted in new stress themes: Relational (Violation-Racial Microaggressions) and Institutional (Time Wasted). The substance use scripts consisted of the following trigger themes: Social (Social Facilitation, Socially-Sanctioned Substance Use Event, Exposure to Substance Use Friends/Associates), Internal (Free Time, Boredom, Thoughts of Using Substance, Frustration, Reward), and Environment (Availability of Substance, Celebration, Party Environment, Food, Hot Day, Money/Payday). The neutral/relaxing scripts themes were: Outdoor Activities (Admiring Nature, People Watching, Observing Surroundings, Enjoying the Sun, Playing in the Sand, Walking), Quiet Activities (Silence/Quiet, Prayer, Reading), and Indoor Activities (Radio, Television, Bath/Shower, Bed/Chair, Observing from a Window). We found sex differences across scripts.

CONCLUSIONS

The results suggest that Black people experience unique stressors (e.g., institutional and racial stressors) that are important to consider when modifying treatment to improve outcomes among this group. In addition to stressors, this study also identified high-risk situations involving triggers for use. Taken together these findings suggest targets for the tailoring of coping strategies that could be incorporated for the development of culturally relevant behavioral treatment for SUD.

Determinants of outpatient substance use disorder treatment length-of-stay and completion: the case of a treatment program in the southeast U.S

Successful outcomes of outpatient substance use disorder treatment result from many factors for clients-including intersections between individual characteristics, choices made, and social determinants. However, prioritizing which of these and in what combination, to address and provide support for remains an open and complex question. Therefore, we ask: What factors are associated with outpatient substance use disorder clients remaining in treatment for > 90 days and successfully completing treatment? To answer this question, we apply a virtual twins machine learning (ML) model to de-identified data for a census of clients who received outpatient substance use disorder treatment services from 2018 to 2021 from one treatment program in the Southeast U.S. We find that primary predictors of outcome success are: (1) attending self-help groups while in treatment, and (2) setting goals for treatment. Secondary predictors are: (1) being linked to a primary care provider (PCP) during treatment, (2) being linked to supplemental nutrition assistance program (SNAP), and (3) attending 6 or more self-help group sessions during treatment. These findings can help treatment programs guide client choice making and help set priorities for social determinant support. Further, the ML method applied can explain intersections between individual and social predictors, as well as outcome heterogeneity associated with subgroup differences.

Opioid and stimulant attributed treatment admissions and fatal overdoses: Using national surveillance data to examine the intersection of race, sex, and polysubstance use, 1992-2020

BACKGROUND

We use national surveillance data to evaluate race/ethnicity by sex/gender differences and trends in substance use treatment admissions and overdose deaths involving opioid and stimulant use.

METHODS

We used data (1992-2019) from the Treatment Episode Dataset-Admissions to identify treatment admissions and the Center for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (1999-2020) to identify overdose deaths. We assessed treatment admissions and related drug overdose deaths per 100,000 adults by sex and race/ethnicity for opioid and stimulant groups: cocaine, opioid, methamphetamines, cocaine and opioid use, cocaine and methamphetamines, and opioid and methamphetamines.

RESULTS

We found significant variations in treatment admissions and deaths by race/ethnicity and sex/gender. Cocaine-related treatment admissions and deaths were most prevalent among Non-Hispanic Black individuals over the study years, yet lower rates were evident among individuals from other racial/ethnic groups. Notably, Non-Hispanic Black men experienced larger increases in cocaine-only admissions than men of other racial/ethnic groups between 1992 and 2019. Men had higher opioid and stimulant treatment admissions and overdose deaths than women. We observed skyrocketing methamphetamine deaths among American Indian/Native Alaskan men and women from 1992 to 2019.

DISCUSSION

Steep increases in overdose deaths fueled by methamphetamines among Non-Hispanic Native Americans and cocaine among Non-Hispanic Black individuals suggest a need for more effective interventions to curb stimulant use. Variations by race/ethnicity and sex/gender also suggest interventions should be developed through an intersectionality lens.

Exploring Gender and Ethnoracial Differences and Trends in Methamphetamine Treatment

Introduction

Given the significant rise in methamphetamine use and related mortality in the United States, it is critical to explore differences in treatment trends with particular attention to women and ethnoracial groups in hard-hit areas like Los Angeles County.

Methods

We analyzed a large sample across 4 waves: 2011 (105 programs, 10 895 clients), 2013 (104 programs, 17 865 clients), 2015 (96 programs, 16 584 clients), and 2017 (82 programs, 15 388 clients). We completed a comparative analysis to identify differences across subgroups and a trend analysis of treatment episodes by gender and ethnoracial group to differentiate users of methamphetamine and users of other drugs.

Results

Treatment clients using methamphetamine increased over time for each gender and race. There were also significant differences across age groups. Women comprised a greater proportion of treatment episodes involving methamphetamine use (43.3%) compared to all other drugs combined (33.6%). Latinas represented 45.5% of methadone-related admissions. Compared with other drug users, methamphetamine users had a lower successful treatment completion rate and were served by programs with less financial and culturally responsive capacity.

Conclusions

Findings highlight a sharp increase in treatment admissions for methamphetamine users of all gender and ethnocultural groups. Women, especially Latinas, saw the most significant increases, with a widening gender gap over time. All subgroups of methamphetamine users had a lower treatment completion rate compared with users of other drugs, and critical differences existed in the programs where they received services.

Outpatient substance abuse treatment completion rates for racial-ethnic minorities during the Great Recession

There has been minimal research linking the effects on racial-ethnic minorities' health outcomes, particularly research focused on racial-ethnic minorities seeking outpatient substance abuse treatment in the United States. The Great Recession from December 2007 to June 2009 in the United States provides the backdrop against the completion of substance abuse treatments among racial-ethnic minorities that may be associated with the impacts on users' social realities. We utilized data from the 2006-2011 Treatment Episode Datasets-Discharge (TEDS-D) dataset which collects data on outpatient substance abuse treatment institutions throughout the United States. The substance abuse treatment completion rates were higher prior to the Great Recession and lower following the Great Recession. Hispanics were more likely than non-Hispanic whites to complete substance abuse treatment, while other minority groups such as Non-Hispanic Blacks, were less likely to do so. Clients in the Northeast and West regions were more likely to successfully complete substance abuse treatment than those in the South. These findings have implications for impacting outpatient substance abuse treatment completion rates following the Great Recession to reduce racial-ethnic disparities which were impacted by region. Even amid an economic recession, treatment for substance abuse should continue to be a top concern.

An evaluation of the association between specific post-overdose care services in emergency departments and subsequent treatment engagement

Objective

The objective of this study was to estimate the association between receipt of specific post-overdose care services in the emergency department (ED) and subsequent engagement in treatment for opioid use disorder (OUD) after discharge.

Methods

This was a retrospective cohort study of Rhode Island residents treated at 1 of 4 EDs for opioid overdose who were not engaged in OUD treatment and were discharged home (May 2016-April 2021). Electronic health record data were used to identify ED services received, and state administrative data were used to define subsequent engagement in OUD treatment within 30 days. Multivariable conditional logistic regression was used to estimate the association between ED services received and subsequent treatment engagement.

Results

Overall, 1008 people not engaged in OUD treatment were treated at study EDs for opioid overdose and discharged home, of whom 146 (14%) subsequently engaged in OUD treatment within 30 days. Most patients were aged 25 to 44 years (59%) and non-Hispanic White (69%). Receipt of behavioral counseling in the ED (adjusted odds ratio [aOR] = 1.79, 95% confidence interval [CI] = 1.18-2.71) and initiation of buprenorphine treatment in/from the ED (aOR = 5.86, 95% CI = 2.70-12.71) were associated with treatment engagement. Receipt of a take-home naloxone kit or naloxone prescription and referral to treatment at discharge were not associated with treatment engagement. Overall, 49% of patients received behavioral counseling in the ED, and 3% initiated buprenorphine in/from the ED.

Conclusion

Strategies for increasing provision of behavioral counseling and initiation of buprenorphine in the ED may be useful for improving subsequent engagement in OUD treatment after discharge.

Nuestra Recuperación [Our Recovery]: using photovoice to understand the factors that influence recovery in Latinx populations

BACKGROUND

Photovoice is a form of visual ethnography intended to engage impacted communities in research followed by action to ameliorate the injustices under study. Photovoice has increased in use, especially in collaboration with Latinx communities addressing health inequities. The Latinx population comprises nearly 18% of the overall United States population and according to the census is projected to reach just under 30% by 2060. This diverse panethnic community faces significant structural barriers in accessing services. Racism and the resulting marginalization, specifically, contributes to limited access to recovery services and treatment. Making meaningful advances in substance use disorder training, intervention and policy necessitates learning alongside the Latinx community.

METHODS

We partnered with a Latinx serving integrated behavioral health and primary care setting in Boston Massachusetts to explore barriers and facilitators to recovery using photovoice. Spanish-speaking Latinx adults with a substance use disorder participated. The group met for three photovoice sessions over a six-week period. Together group members critically analyzed photographs using the SHOWeD method.

RESULTS

Findings indicate a sense of purpose and meaning, security, faith and housing are important elements of recovery. The results illustrated the importance of sources of connection in maintaining sobriety. Through this photovoice project, Latinx Spanish speaking participants highlighted barriers and facilitators to their substance use disorder recovery which spanned individual, community, and structural levels.

CONCLUSIONS

The experiences and voices of the Latinx community are crucial to drive discussions that advance policy (e.g., housing stability and access), enhance providers' understanding of Latinx Spanish-speakers' substance use disorder recovery, and inform culturally and linguistically appropriate services. This study demonstrated that photovoice is highly acceptable and feasible among Latinx clients receiving substance use disorder services. Visual images related to housing, faith, etc. communicate challenges, power structures, as well as hopes to policymakers at multiple levels (e.g., institution/ agency, state).

Perspectives on the therapeutic potential of MDMA: A nation-wide exploratory survey among substance users

Background

Alcohol and other substance use disorders are commonly associated with post-traumatic stress disorder (PTSD), and the presence of these comorbidities is associated with worse treatment outcomes. Additionally, disparities in substance and PTSD prevalence have been associated with minority races and ethnicities, and minorities have been shown to be less likely to engage in treatment. Psychedelic-assisted treatments, including 3,4-methylenedioxymethamphetamine (MDMA), have shown preliminary trans-diagnostic effectiveness, however it is unknown how individuals with substance use disorders view the therapeutic potential of MDMA therapy. Previous studies have also shown that minority races and ethnicities are under-represented in the MDMA trials, leading to concerns about inequitable access to clinical treatment.

Methods

To explore demographic characteristics related to patient-level perspectives on the therapeutic potential of MDMA-assisted therapy, this study describes data from a nationwide, cross-sectional survey of 918 individuals self-reporting criteria consistent with alcohol or substance use disorders.

Results

Overall, a majority of individuals reported support for medical research of MDMA (68.1%), belief that MDMA-assisted therapy might be a useful treatment (70.1%), and willingness to try MDMA-assisted therapy if it were determined to be an appropriate treatment for them (58.8%). No race or ethnicity differences were found in support for further research or belief in effectiveness, however there were small disparities in terms of willingness to try MDMA-assisted therapy and concerns related to use of this treatment approach.

Conclusion

These results provide insights and future directions as the field of psychedelic-assisted therapy seeks to provide equitable access to clinical care and to diversify research participation.

Associations of tobacco cigarette use and dependence with substance use disorder treatment completion by sex/gender and race/ethnicity

INTRODUCTION

Individuals with substance use disorders (SUD) are approximately five times more likely to smoke cigarettes than the general population. Individuals who smoke cigarettes have greater odds of SUD relapse compared to individuals who do not smoke cigarettes, but we know little about how cigarette use is related to SUD treatment completion overall by sex/gender or race/ethnicity.

METHODS

This study examined 2855 adults (71.98 % male; >70 % racial/ethnic minority) in outpatient and residential SUD treatment at a New York-based treatment agency over a six-month period in 2018.

RESULTS

Overall, approximately three-fourths of SUD treatment-seeking participants smoked cigarettes, with high rates across sex/gender and racial/ethnic groups. Nicotine dependence did not differ by sex/gender, and White Non-Hispanic adults had the highest levels of nicotine dependence across racial/ethnic groups. Those who smoked cigarettes were significantly less likely to complete treatment compared to those who did not smoke cigarettes (OR = 0.69; 95 % CI: 0.58, 0.82). The study found no overall differences in SUD treatment completion and length of stay by sex/gender or race/ethnicity.

CONCLUSIONS

Given the high prevalence of cigarette smoking and lower odds of completing SUD treatment, the current system of care for SUD treatment may be enhanced by addressing cigarette smoking from onset of treatment.

Treatment outcomes associated with medications for opioid use disorder (MOUD) among criminal justice-referred admissions to residential treatment in the U.S., 2015-2018

AIMS

To examine the use and association of medications for opioid use disorder (MOUD) with treatment completion and retention for criminal justice referred (CJR) admissions to residential treatment.

METHODS

A retrospective analysis of the Treatment Episode Dataset-Discharge (TEDS-D; 2015-2018) for adults (N = 205,348) admitted to short-term (ST) (< 30 days) or long-term (LT) (>30 days) residential treatment for OUD. Outcomes were MOUD in treatment plans, and treatment completion and retention (ST >10 days; LT > 90 days). Logistic regression analyses were conducted separately for ST and LT settings.

RESULTS

CJR admissions were less likely to have MOUD than non-CJR admissions (ST, 11% vs. 21%; LT, 10% vs. 24%, respectively) and were more likely to complete and be retained in treatment. In ST settings, MOUD was associated with higher likelihood of treatment completion and retention. In LT settings, MOUD was associated with higher likelihood of treatment retention and lower likelihood of treatment completion. These associations tended to be slightly weaker for CJR admissions, with the exception of treatment completion in LT settings, but the moderating effect size of CJR status in all models was very small. Small differences in the moderating effect of CJR status by race and ethnicity were observed in LT settings.

CONCLUSIONS

MOUD is greatly under-utilized for CJR patients, and given that MOUD was associated with positive outcomes, there is a critical need to find ways to increase access to MOUD for CJR patients in residential treatment. Race and ethnicity appear to have relatively little impact on outcomes.

Technology-Based Interventions in Substance Use Treatment to Promote Health Equity Among People Who Identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native: Protocol for a Scoping Review

BACKGROUND

Technology-based interventions (TBIs; ie, web-based and mobile interventions) have the potential to promote health equity in substance use treatment (SUTx) for underrepresented groups (people who identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native) by removing barriers and increasing access to culturally relevant effective treatments. However, technologies (emergent and more long-standing) may have unintended consequences that could perpetuate health care disparities among people who identify as a member of one of the underrepresented groups. Health care research, and SUTx research specifically, is infrequently conducted with people who identify with these groups as the main focus. Therefore, an improved understanding of the literature at the intersection of SUTx, TBIs, and underrepresented groups is warranted to avoid exacerbating inequities and to promote health equity.

OBJECTIVE

This study aims to explore peer-reviewed literature (January 2000-March 2021) that includes people who identify as a member of one of the underrepresented groups in SUTx research using TBIs. We further seek to explore whether this subset of research is race/ethnicity conscious (does the research consider members of underrepresented groups beyond their inclusion as study participants in the introduction, methods, results, or discussion).

METHODS

Five electronic databases (MEDLINE, Scopus, Cochrane Library, CINAHL, and PsycInfo) were searched to identify SUTx research using TBIs, and studies were screened for eligibility at the title/abstract and full-text levels. Studies were included if their sample comprised of people who identify as a member of one of the underrepresented groups at 50% or more when combined.

RESULTS

Title/abstract and full-text reviews were completed in 2021. These efforts netted a sample of 185 studies that appear to meet inclusionary criteria. Due to the uniqueness of tobacco relative to other substances in the SUTx space, as well as the large number of studies netted, we plan to separately publish a scoping review on tobacco-focused studies that meet all other criteria. Filtering for tobacco-focused studies (n=31) netted a final full-text sample for a main scoping review of 154 studies. The tobacco-focused scoping review manuscript is expected to be submitted for peer review in Spring 2022. The main scoping review data extraction and data validation to confirm the accuracy and consistency of data extraction across records was completed in March 2022. We expect to publish the main scoping review findings by the end of 2022.

CONCLUSIONS

Research is needed to increase our understanding of the range and nature of TBIs being used in SUTx research studies with members of underrepresented groups. The planned scoping review will highlight research at this intersection to promote health equity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34508.

Factors supporting substance use improvement for Black Americans: A population health observational study

BACKGROUND

Black clients in substance use disorder (SUD) treatment are associated with the lowest successful completion and substance use reductions. More work is needed to identify specific factors that support successful recovery of Black clients.

METHODS

Data from U.S. outpatient SUD treatment facilities receiving public funding from 2015 to 2019 were analyzed (N = 2239,197). Primary analyses consisted of Black clients (n = 277,726) reporting admission and discharge substance use frequency. Multiple logistic regression was used to predict substance use frequency improvement from Black client demographic, recovery capital, treatment characteristics, and state. Disparities were compared between Black and non-Black clients.

RESULTS

The overall Black client improvement percentage was 46.95%. Mutual-help group attendance and Length of Stay demonstrated clinically meaningful effect sizes controlling for all other variables and state. Attending mutual-help groups 8-30 times per month (State aOR = 2.54, 95% CI = 2.43, 2.64) and outpatient treatment stays of 4 months or more (State aOR = 2.50, 95% CI = 2.44, 2.56) were factors supporting Black client improvement. Importantly, states are associated with disparate Black client risk differences and only South Dakota had greater Black improvement (RD = 6.35, 95% CI = 1.00, 11.71).

CONCLUSIONS

Black client factors supporting substance use improvement include ancillary mutual-help group attendance and increased treatment retention. These factors may be more critical in states with larger Black improvement disparities. In general, treatment providers increasing access to mutual-help groups, and adjusting program inclusiveness and motivational factors for retention, would make strides in increasing improvement outcomes for Black clients.

The impact of self-help groups on successful substance use treatment completion for opioid use: An intersectional analysis of race/ethnicity and sex

INTRODUCTION

Race/ethnicity and sex disparities in substance use and substance use treatment completion are well documented in the literature. Previous literature has shown that participation in self-help groups is associated with higher rates of substance use treatment completion. While most of this research has focused on the completion of treatment for alcohol and stimulant use, research examining this relationship using an intersectional approach for individuals in treatment for opioid use is limited.

METHODS

Thus, the current study utilized responses from the Treatment Episodes Data Set-Discharges, 2015-2017 to examine disparities in the relationship between participation in self-help groups and substance use treatment completion for individuals undergoing treatment for opioid use based on sex, race, and ethnicity.

RESULTS

Results revealed a positive association between participation in self-help groups and treatment completion among those in treatment for opioid use across race, ethnicity, and sex. Further, the study found several differences in this association based on one's race, ethnicity, and sex. When compared to men of other races/ethnicities, the association between self-help group participation and treatment completion was highest among Black men.

CONCLUSIONS

The results of the current study extend the knowledge-base about self-help participation's role in promoting successful substance use treatment completion to individuals in treatment for opioid use. Results also highlight the need to examine treatment outcomes with an intersectional lens.

Disparities in expected driving time to opioid treatment and treatment completion: findings from an exploratory study

BACKGROUND

Commuting time to treatment has been shown to affect healthcare outcomes such as engagement and initiation. The purpose of this study is to extend this line of research to investigate the effects of driving time to opioid programs on treatment outcomes.

METHODS

We analyzed discharge survey data from 22,587 outpatient opioid use disorder treatment episodes (mainly methadone) in Los Angeles County and estimated the associated driving time to each episode using Google Maps. We used multivariable logistic regressions to examine the association between estimated driving time and odds of treatment completion after adjusting for possible confounders.

RESULTS

Findings show an average driving time of 11.32 min and an average distance of 11.18 km. We observed differences in estimated driving time across age, gender, and socioeconomic status. Young, male, less formally educated, and Medi-Cal-ineligible clients drove longer to treatment. A 10-min drive was associated with a 33% reduction in the completion of methadone treatment plans (p < .01).

CONCLUSION

This systemwide analysis provides novel time estimates of driving-based experiences and a strong relationship with completion rates in methadone treatment. Specifically, the result showing reduced treatment completion rates for drive times longer than 10 min may inform policies regarding the ideal geographic placement of methadone-based treatment programs and service expansion initiatives.

Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US

BACKGROUND

This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion.

METHODS

Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors.

RESULTS

After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776).

CONCLUSIONS

Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.

The intersection of race and opioid use disorder treatment: A quantitative analysis

INTRODUCTION

Racial health inequities exist in the United States. Racial minorities and whites have different health care experiences and health outcomes. Past studies examined this relationship for health care treatment, but additional research on whether and how race affects treatment for opioid use disorder (OUD) is needed. Based on systematic racism theory, this study examines the relationship between race and OUD treatment in three ways, representing three different phases in the treatment process: referral source for treatment, whether the treatment plan includes medications for OUD (MOUD), and reason for discharge.

METHODS

This study examines the relationship between race and treatment for OUD. The study uses data from the 2013 and 2017 Treatment Episode Data Set Discharges (TEDS-D) dataset to run logistical and multinomial regression models.

RESULTS

This study found that a relationship between race and treatment for OUD exists in all three areas that we examined. Specifically, this study found that being a minority was associated with a decreased likelihood of being referred to treatment by a medical professional, a decreased likelihood of having MOUD as part of the treatment plan (although the opposite was true in 2013), and a decreased likelihood of leaving treatment because the treatment episode was complete.

CONCLUSION

Policymakers should use these findings to develop policy interventions for OUD that recognize the systematic racism that exists rather than our current colorblind policies.

Predictive validity of the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for continuous engagement in treatment among individuals recommended for outpatient care

BACKGROUND

The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. However, research has not studied its predictive validity. We examined the predictive validity of the LOCADTR recommendation for outpatient treatment by determining whether those who entered a level of care (LOC) concordant with the LOCADTR recommendation differed in continuous engagement in treatment compared to those who entered a discordant LOC.

METHODS

The study combined data from two NYS administrative sources, the LOCADTR database and a treatment registry. The study examined characteristics of the clients who entered concordant and discordant LOCs as well as tested for differences in continuous engagement of clients who entered discordant care compared to a propensity score-matched comparison group of clients who entered the concordant LOC.

RESULTS

Among clients for whom the LOCADTR recommended the outpatient LOC, concordant clients who entered the outpatient LOC were more likely to be retained in care than discordant clients who entered the inpatient LOC (aOR = 0.53; 95% CI = 0.36, 0.77). We did not observe statistical differences in continuous engagement among clients who were recommended for outpatient and entered that LOC versus those who entered the outpatient rehabilitation LOC instead (aOR = 1.08; 95% CI = 0.90, 1.30).

CONCLUSION

This study provides support for predictive validity of recommendations stemming from the LOCADTR. Clients, treatment providers, and payers benefited from a tool that provides clear guidance and predictively valid recommendations for treatment placement. The study found that clients were more likely to be retained in treatment for 6 months or longer if admitted to outpatient care, as recommended by the LOCADTR algorithm, rather than to inpatient treatment. One factor accounting for the longer engagement in outpatient care is the low level of continuity of care among patients being discharged from inpatient treatment.

Gender disparities in opioid treatment progress in methadone versus counseling

BACKGROUND

In the United States, the high dropout rate (75%) in opioid use disorder (OUD) treatment among women and racial/ethnic minorities calls for understanding factors that contribute to making progress in treatment. Whereas counseling and medication for OUD (MOUD, e.g. methadone, buprenorphine, naltrexone) is considered the gold standard of care in substance use disorder (SUD) treatment, many individuals with OUD receive either counseling or methadone-only services. This study evaluates gender disparities in treatment plan progress in methadone- compared to counseling-based programs in one of the largest SUD treatment systems in the United States.

METHODS

Multi-year and multi-level (treatment program and client-level) data were analyzed using the Integrated Substance Abuse Treatment to Eliminate Disparities (iSATed) dataset collected in Los Angeles County, California. The sample consisted of 4 waves: 2011 (66 SUD programs, 1035 clients), 2013 (77 SUD programs, 3686 clients), 2015 (75 SUD programs, 4626 clients), and 2017 (69 SUD programs, 4106 clients). We conducted two multi-level negative binomial regressions, one per each outcome (1) making progress towards completing treatment plan, and (2) completing treatment plan. We included outpatient clients discharged on each of the years of the study (over 95% of all clients) and accounted for demographics, wave, homelessness and prior treatment episodes, as well as clients clustered within programs.

RESULTS

We detected gender differences in two treatment outcomes (progress and completion) considering two outpatient program service types (MOUD-methadone vs. counseling). Clients who received methadone vs. counseling had lower odds of completing their treatment plan (OR = 0.366; 95% CI = 0.163, 0.821). Female clients receiving methadone had lower odds of both making progress (OR = 0.668; 95% CI = 0.481, 0.929) and completing their treatment plan (OR = 0.666; 95% CI = 0.485, 0.916) compared to male clients and receiving counseling. Latina clients had lower odds of completing their treatment plan (OR = 0.617; 95% CI = 0.408, 0.934) compared with non-Latina clients.

CONCLUSIONS

Clients receiving methadone, the most common and highly effective MOUD in reducing opioid use, were less likely to make progress towards or complete their treatment plan than those receiving counseling. Women, and in particular those identified as Latinas, were least likely to benefit from methadone-based programs. These findings have implications for health policy and program design that consider the need for comprehensive and culturally responsive services in methadone-based programs to improve outpatient treatment outcomes among women.

Social vulnerabilities for substance use: Stressors, socially toxic environments, and discrimination and racism

Applying a social determinants of health framework, this review brings attention to evidence from social sciences and neuroscience on the role of selected social factors in individual and population-level vulnerability to substance use and substance use disorders (SUDs). The understanding that social vulnerability to substance use and SUDs is multifaceted and occurs across different levels of influence (individual, interpersonal, community, and societal) is underscored. We propose that socially based stressors play a critical role in creating vulnerability to substance use and SUDs, and as such, deserve greater empirical attention to further understand how they "get under the skin." Current knowledge from social sciences and neuroscience on the relationships among vulnerability to substance use resulting from stressors, exposure to socially toxic childhood environments, and racism and discrimination are summarized and discussed, as are implications for future research, practice, and policy. Specifically, we propose using a top-down approach to the examination of known, yet often unexplored, relationships between vulnerability to substance use and SUDs, related inequities, and potential differential effects across demographic groups. Finally, research gaps and promising areas of research, practice, and policy focused on ameliorating social vulnerabilities associated with substance use and SUDs across the lifespan are presented. This article is part of the special issue on 'Vulnerabilities to Substance Abuse'.

Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients

BACKGROUND

The prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene.

OBJECTIVE

To assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection.

DESIGN

Data drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov : NCT01825057).

PARTICIPANTS

A total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study.

MAIN MEASURES

Data sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records.

KEY RESULTS

Provider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08-1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively).

CONCLUSIONS

Findings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.

An Evaluation of Opioid Use in Black Communities: A Rapid Review of the Literature

BACKGROUND

There are multiple aspects of the opioid crisis among Black people, who have been left out of the broader conversation. Despite evidence of increased opioid overdose deaths, less is known about opioid use among Black people. This review synthesizes research on Black people who use opioids; the goals are to advance knowledge, highlight research gaps, and inform clinical practice.

METHODS

This rapid review investigating opioid use among Black people utilized systematic review methods and was conducted according to a predefined protocol with clear inclusion criteria (PROSPERO ID: 177071). A comprehensive search strategy was used, including published and gray-literature sources (i.e., literature that has not been formally published). A narrative summary of the results is presented.

RESULTS

A total of 76 works were selected for inclusion and full text review. Sex, age, geographic location, and involvement in the carceral system were associated with the use of opioids among Black individuals. Non-epidemiologic factors included treatment-seeking patterns, disparate clinician prescribing, and social determinants.

CONCLUSIONS

Through this rapid review we suggest three main areas of focus: (1) including culturally informed collection methods in epidemiologic surveys to accurately reflect prevalences, (2) funding research that specifically addresses the importance of culture in accessing treatment, and (3) directly studying how social determinants can improve or exacerbate health outcomes. Focusing on the unique needs of Black people who use opioids is warranted to increase treatment initiation and adherence among a population less likely to engage with the traditional health care system.

Dismantling racism against Black, Indigenous, and people of color across the substance use continuum: A position statement of the association for multidisciplinary education and research in substance use and addiction

The Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) acknowledges that racism profoundly affects persons who use alcohol and other drugs. Racism's deadly effects compounded with other social determinants of health result in a cascade of negative impacts. The AMERSA Board of Directors (BOD) proposes an initial set of strategies to promote diversity, equity, and inclusion using a framework that speaks to four key AMERSA experiences: engagement, education, mentorship, and leadership. Through these strategies, AMERSA commits to promoting equity and inclusion to dismantle the individual, institutional, and structural racism that has permeated the United States for centuries.

The Epidemiology of Cocaine Use Among Hispanic Individuals: Findings From the 2015-2018 National Survey of Drug Use and Health

Cocaine use disproportionately affects several social groups, including ethnic and sexual minorities. The present study sought to identify the epidemiology of cocaine use among a national sample of Hispanic young adults using pooled data from the 2015-2018 National Survey of Drug Use and Health. Weighted analyses were used to identify correlates to past-year cocaine use. Results revealed that 4.11% (n = 729) of individuals used cocaine in the past year. Individuals who identified as gay/lesbian or bisexual, who drove under the influence of alcohol in the past year, and who reported prior drug use were at risk of cocaine use. Of concern, nearly 10% of gay/lesbian Hispanic individuals report having used cocaine in the past year. Furthermore, cocaine use was associated with other risky behaviors; 41.1% of LSD (Lysergic acid diethylamide) users also reported cocaine use, and 18.2% of cocaine users reported having driven under the influence of alcohol within the past year. Findings from the present study may inform harm reduction efforts and health prevention messages.

Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation

Background

Little is known about the stability of public drug treatment in the United States to deliver services in an era of expansion of public insurance. Guided by organizational theories, we examined the role of program size, and performance (i.e., rates of treatment initiation and engagement) on discontinuing services in one of the largest treatment systems in the United States.

Methods

This study relied on multi-year (2006–2014) administrative data of 249,029 treatment admission episodes from 482 treatment programs in Los Angeles County, CA. We relied on survival regression analysis to identify associations between program size, treatment initiation (wait time) and engagement (retention and completion rates) and discontinuing services in any given year. We examined program differences between discontinued versus sustained services in pre- and post-expansion periods.

Results

Sixty-two percent of programs discontinued services at some point between 2006 and 2014. Program size and rates of treatment retention were negatively associated with risk of discontinuing services. Proportion of female clients was also negatively associated with risk of discontinuing services. Compared to residential programs, methadone programs were associated with reduced likelihood of discontinuing services. Two interactions were significant; program size and retention rates, as well as program size and completion rates were negatively associated with risk of discontinuing services.

Conclusions

Program size (large), type (methadone), performance (retention) and client population (women) were associated with stability in this drug treatment system. Because more than 70% of programs in this system are small, it is critical to support their capacity to sustain services to reduce existing disparities in access to care. We discuss the implications of these findings for system evaluation and for responding to public health crises.

The effect of medications for opioid use disorder (MOUD) on residential treatment completion and retention in the US

BACKGROUND

This study examines whether MOUD increases treatment completion and retention in both short-term (ST) and long-term (LT) residential programs using a national dataset.

METHODS

Data were extracted from the 2015-2017 TEDS-D (Treatment Episode Dataset-Discharge) datasets for opioid using adults in ST (n = 87,296) and LT (n = 66,623) residential treatment. Primary outcome variables were treatment completion and retention (ST: length of stay >10 days; LT: >90 days). Logistic regression estimated the effects of MOUD on the probability of treatment completion and retention separately for ST and LT residential treatment, controlling for individual background characteristics.

RESULTS

Only 18% of clients in residential treatment programs had MOUD in their treatment plans. For ST residential treatment, MOUD was associated with a 40% increased likelihood of treatment completion (OR = 1.404) and 34% increased retention (OR = 1.337). For LT residential treatment, MOUD was associated with a 26% reduced likelihood of treatment completion (OR = 0.743) and no significant increase in retention. Post hoc analysis suggests insurance coverage may be influencing outcomes.

CONCLUSIONS

Despite MOUD being a standard of care for OUD, MOUD is particularly under-utilized in residential treatment. Further research should focus on how best to integrate MOUD within short-term residential treatment and to explore the potential viability of MOUD in long-term residential programs. Given the risk of overdose following residential treatment, for at least short-term residential programs, this setting may be advantageous for integrating psychosocial treatments with early MOUD engagement in a structured therapeutic environment as part of a long-term continuum of care recovery program.

Pretreatment social network characteristics relate to increased risk of dropout and unfavorable outcomes among women in a residential treatment setting for substance use

Increased retention in residential treatment for substance use disorder (SUD) has been associated with more favorable clinical outcomes for residents. Yet SUD treatment dropout remains high. It is essential to uncover factors contributing to these high rates. Little is known about whether features of an individual's social network prior to treatment entry are related to number of days in treatment or to clinical status at treatment termination. To examine these relationships, we analyzed data from 241 women (58.5% Hispanic) entering an SUD residential treatment facility, who agreed to participate in a parent randomized control trial. We assessed characteristics of these women's social networks prior to treatment entry at baseline. We extracted clinician-determined progress at treatment termination and days in treatment two months after treatment entry from clinical records. Data-driven analyses using purposeful selection of predictors showed that the overall size of the social network was associated with increased likelihood of being classified as having achieved good clinical progress in treatment at termination and that number of drug users in the pretreatment social network was related to staying fewer days in treatment. Contrary to our hypothesis, we found no significant associations between other pretreatment social support network characteristics (i.e., social support) and treatment retention or clinical discharge status. Future research should examine how features of social networks change through treatment and how these changes relate to treatment outcomes.

Substance use improvement depends on Race/Ethnicity: Outpatient treatment disparities observed in a large US national sample

BACKGROUND

Racial/ethnic disparities exist at many levels of substance use disorder (SUD) treatment and recovery, reflecting biological and socioeconomic factors. However, racial/ethnic disparities in SUD treatment effectiveness have not been sufficiently investigated.

METHODS

Data for US outpatient SUD treatment facilities receiving public funding from 2015 to 2017 were analyzed using the Treatment Episode Datasets-Discharge (TEDS-D). The study sample (N = 72,242) were White (n = 51,663), Black (n = 11,789), and Latino (n = 8782) clients reporting substance use frequency at admission and discharge. Multiple logistic regression was used to predict substance use improvement from race/ethnicity, socioeconomic variables, and their interactions. Moderating effects and their clinically meaningful effect sizes of risk differences (RD) were of primary interest.

RESULTS

The simple improvement comparison was statistically significant (χ²_[2] = 380.59, p < 0.0001). Latino clients improved more (RD = 5.12, 95 % CI = 4.02, 6.22) and Black clients improved less than White clients (RD = -7.93, 95 % CI = -8.93, -6.93). However, race/ethnicity significantly and meaningfully moderated the relationship between substance use improvement and age, employment status, problem substance, and referral source (Wald χ²_[77] = 5005.94, p < 0.0001).

CONCLUSIONS

Latinos demonstrated greater use improvement than Black and White clients. Socioeconomic characteristics moderated this general tendency. Culturally sensitive treatments can be enhanced by addressing culturally specific needs according to client age, employment, specific problem substance, and referral source. For example, Black clients referred from school improved more than Whites and Latinos. Increasing resources for school referrals may further improve Black client outcomes.

Medication for opioid use disorder treatment and specialty outpatient substance use treatment outcomes: Differences in retention and completion among opioid-related discharges in 2016

Opioid medication treatment access is a public health priority aimed to improve opioid use treatment outcomes. However, Medicaid does not cover all forms of MOUD, particularly methadone, in many states. We examined associations between medication for opioid use disorder (MOUD) plans and substance use treatment discharge reason (e.g., completed treatment, dropped out of treatment) as well as treatment retention (i.e., length of stay), and estimated whether these relationships were modified by state Medicaid methadone coverage. Data from the 2016 Treatment Episode Data Set for Discharges (TEDS-D) included 152,196 opioid-related treatment episodes from 47 states using relative risk regression with state clustering. Discharges involving MOUD had higher treatment retention for >180 days (aRR: 1.60, 95% CI: 1.29, 1.99) and >365 days (aRR: 2.64, 95% CI: 2.00, 3.49) but lower treatment completion (aRR: 0.46, 95% CI: 0.38, 0.57). There was no evidence that state Medicaid methadone coverage modified any of these relationships. Focusing on treatment completion alone may obscure health benefits associated with longer MOUD treatment retention.

Adolescent treatment admissions for marijuana following recreational legalization in Colorado and Washington

INTRODUCTION

There is concern that recreational marijuana legalization (RML) may lead to increased cannabis use disorder (CUD) among youth due to increased marijuana use. This study investigates whether adolescent substance use disorder treatment admissions for marijuana use increased in Colorado and Washington following RML.

METHODS

Annual data on 2008-2017 treatment admissions for marijuana use from the SAMHSA TEDS-A dataset for adolescents age 12-17 were used to model state treatment admissions trends. Difference-in-differences models were used to investigate whether treatment admissions increased following RML in Colorado/Washington compared to non-RML states, after adjusting for socioeconomic characteristics and treatment availability.

RESULTS

Over all states in the analysis, the rate of adolescent treatment admissions for marijuana use declined significantly over the study period (β=-3.375, 95 % CI=-4.842, -1.907), with the mean rate falling nearly in half. The decline in admissions rate was greater in Colorado and Washington compared to non-RML states following RML, though this difference was not significant (β=-7.671, 95 % CI=-38.798, 23.456).

CONCLUSION

Adolescent treatment admissions for marijuana use did not increase in Colorado and Washington following RML. This may be because youth marijuana use did not increase, CUD did not increase (even if use did increase), or treatment seeking behaviors changed due to shifts in attitudes and perceptions of risk towards marijuana use.

Dual mental health diagnoses predict the receipt of medication-assisted opioid treatment: Associations moderated by state Medicaid expansion status, race/ethnicity and gender, and year

BACKGROUND

Mental health diagnoses (MHD) are common among those with opioid use disorders (OUD). Methadone/buprenorphine are effective medication-assisted treatment (MAT) strategies; however, treatment receipt is low among those with dual MHDs. Medicaid expansions have broadly increased access to OUD and mental health services over time, but MAT uptake may vary depending on multiple factors, including MHD status, state Medicaid expansion decisions, and race/ethnicity and gender. Examining clinical and policy approaches to promoting MAT uptake may improve services among marginalized groups.

METHODS

MAT treatment discharges were identified using the Treatment Episodes Dataset-Discharges (TEDS-D; 2014-2017) (n = 1,400,808). We used multivariate logistic regression to model MAT receipt using interactions and adjusted for several potential confounders.

RESULTS

Nearly one-third of OUD treatment discharges received MAT. Dual MHDs in both expansion and non-expansion states were positively associated with MAT uptake over time. Dual MHDs were negatively associated with MAT receipt only among American Indian/Alaska Native women residing in Medicaid expansion states (aOR = 0.58, 95 % CI = 0.52-0.66, p < 0.0001).

CONCLUSION

Disparities in MAT utilization are nuanced and vary widely depending on dual MHD status, Medicaid expansion, and race/ethnicity/gender. Medicaid is beneficial but not a universal treatment panacea. Clinical decisions to initiate MAT are dependent on multiple factors and should be tailored to meet the needs of high-risk, historically disadvantaged clients.