Racial/ethnic differences in treatment for substance use disorders among U.S. adolescents

Inequities in naloxone administration among fatal overdose decedents by race and ethnicity in Pennsylvania, 2019-21

AIMS

The aim of this study was to characterize the circumstances of drug overdose deaths and determine whether naloxone administration differed by overdose decedent race and ethnicity.

DESIGN AND SETTING

Analysis of data on unintentional and undetermined intent drug overdose deaths in Pennsylvania (2019-21) was collected from death certificates and the State Unintentional Drug Overdose Reporting System. Multivariable logistic regression models were adjusted for overdose death circumstances and the odds of naloxone administration were estimated by race/ethnicity and year.

CASES

The analytical sample included 3386 fatal overdose decedents in 2019, 3864 in 2020 and 3816 in 2021.

MEASUREMENTS

Evidence of naloxone administration (yes/no) was defined using scene evidence and toxicology reports from coroner and medical examiner records, while race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White) was based on the death certificate.

FINDINGS

In the analytic sample, overdose death rates were the highest among Black people and increased over time (rate per 10 000 population, 2019: 4.3; 2020: 6.1; 2021: 6.5); rates were lowest among White people and remained constant over time (rate per 10 000 population, 2019: 2.6; 2020: 2.7; 2021: 2.6). Throughout all years, Black decedents had approximately 40-50% lower odds of naloxone administration compared with White decedents as referent [2019: odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.5-0.9; 2020: OR = 0.5, 95% CI = 0.4-0.7; 2021: OR = 0.6, 95% CI = 0.5-0.8], while Hispanic decedents had similar odds of naloxone administration to that of White decedents.

CONCLUSION

After controlling for overdose circumstances in drug overdose deaths in Pennsylvania, USA, from 2019 to 2021, Black people had lower odds of naloxone administration compared with White people, while there were no differences between Hispanic and White people.

Creating an Equitable System of Care for Minoritized Youth and Addressing Systemic and Structural Barriers

We provide an overview of the systems of care and the barriers faced by minoritized youth. We discuss ways to address barriers by forging alliances, improving communication with cultural humility, and a nonjudgmental approach. We underscore the importance of a holistic evaluation of minoritized children while leveraging their resilience to create a comprehensive and multipronged plan of action.

Understanding cultural inclusion in alcohol and other drug services in New South Wales, Australia and assessing the acceptability of a cultural inclusion audit

INTRODUCTION

Cultural inclusion and competence are understood at the most basic level to be the practice of considering culture so as to provide effective services to people of different cultural backgrounds. In order to work better with clients from diverse backgrounds, alcohol and other drug (AOD) services need to offer a service that is designed to be accessible to all people, where systems in place operate in a way that considers different cultural needs. This research aimed to assess the extent to which non-government AOD services in New South Wales are positioned to support cultural inclusion as well as to evaluate the acceptability of a cultural inclusion audit across four AOD sites.

METHODS

The research adopted a mixed methods approach comprising of a pre-audit online survey (n = 85) designed to assess AOD services' attitudes and practices towards cultural inclusion, and in-depth interviews that were conducted with nine AOD service staff and four cultural auditors to explore the acceptability of a cultural inclusion audit process.

RESULTS

Findings from the survey indicate cultural inclusion practices are limited. Interview data highlight that while staff are not fully aware of what appropriate cultural inclusions entails, they are receptive to and want a cultural inclusion program.

DISCUSSION AND CONCLUSIONS

The study illustrates the benefits of implementing a cultural inclusion audit process aimed at raising awareness of what cultural inclusion entails. Including a cultural inclusion service audit is likely to enhance AOD service provision to culturally and linguistically diverse groups and thereby improve treatment outcomes.

Addiction Medicine Treatment Utilization by Race/Ethnicity Among Adolescents With Substance Use Problems Before Versus During the COVID-19 Pandemic

PURPOSE

To examine changes in addiction medicine treatment utilization during the COVID-19 pandemic among adolescents (aged 13-17 years) and differences by race/ethnicity.

METHODS

We compared treatment initiation (overall and telehealth), engagement, and 12-week retention between insured adolescents with substance use problems during pre-COVID-19 (March to December 2019, n = 1,770) and COVID-19 (March to December 2020, n = 1,177) using electronic health record data from Kaiser Permanente Northern California.

RESULTS

Compared to pre-COVID-19, odds of treatment initiation, overall (adjusted odds ratio [95% confidence interval] = 1.42 [1.21-1.67]), and telehealth (5.98 [4.59-7.80]) were higher during COVID-19, but odds of engagement and retention did not significantly change. Depending on the outcome, Asian/Pacific Islander, Black, and Latino/Hispanic (vs. White) adolescents had lower treatment utilization across both periods. Changes in utilization over time did not differ by race/ethnicity.

DISCUSSION

Addiction medicine treatment initiation increased among insured adolescents during the pandemic, especially via telehealth. Although racial/ethnic disparities in treatment utilization persisted, they did not worsen.

Provider perceptions of systems-level barriers and facilitators to utilizing family-based treatment approaches in adolescent and young adult opioid use disorder treatment

BACKGROUND

Amidst increasing opioid-related fatalities in adolescents and young adults (AYA), there is an urgent need to enhance the quality and availability of developmentally appropriate, evidence-based treatments for opioid use disorder (OUD) and improve youth engagement in treatment. Involving families in treatment planning and therapy augments medication-based OUD treatment for AYA by increasing treatment engagement and retention. Yet, uptake of family-involved treatment for OUD remains low. This study examined systems-level barriers and facilitators to integrating families in AYA OUD treatment in Rhode Island.

METHODS

An online survey was administered to clinic leaders and direct care providers who work with AYA in programs that provide medication and psychosocial treatments for OUD. The survey assessed attitudes towards and experiences with family-based treatment, barriers and facilitators to family-based treatment utilization, as well as other available treatment services for AYA and family members. Findings were summarized using descriptive statistics.

RESULTS

A total of 104 respondents from 14 distinct treatment programs completed the survey. Most identified as White (72.5%), female (72.7%), and between 25 and 44 years of age (59.4%). Over half (54.1%) of respondents reported no experience with family based treatment and limited current opportunities to involve families. Barriers perceived as most impactful to adopting family-based treatment were related to limited available resources (i.e. for staff training, program expansion) and lack of prioritization of family-based treatment in staff productivity requirements. Barriers perceived as least impactful were respondent beliefs and attitudes about family-based treatment (e.g., perception of the evidence strength and quality of family-based treatment, interest in implementing family-based treatment) as well as leadership support of family-based treatment approaches. Respondents identified several other gaps in availability of comprehensive treatment services, especially for adolescents (e.g. services that increase social recovery capital).

CONCLUSIONS

Family-based treatment opportunities for AYA with OUD in Rhode Island are limited. Affordable and accessible training programs are needed to increase provider familiarity and competency with family-based treatment. Implementation of programming to increase family involvement in treatment (i.e. psychoeducational and skills-based groups for family members) rather than adopting a family-based treatment model may be a more feasible step to better meet the needs of AYA with OUD.

TRIAL REGISTRATION

not applicable.

Mixed-Methods Examination of Adolescent-Reported Barriers to Accessing Mental Health Services

PURPOSE

Many adolescents struggle to access the mental healthcare they need. To increase access to mental health services, we must have a clear understanding of the barriers adolescents face from their own perspectives. This online mixed-methods study aimed to enhance understanding of access barriers by centering the perspectives of diverse adolescents who had recently tried and failed to access mental health support.

METHODS

In this convergent parallel mixed-methods study, adolescents responded to a preintervention, open-ended question about barriers they have faced to accessing mental health services when they needed them and shared information about their background and depressive symptoms. Barriers were assessed using inductive, conventional content analysis. Quantitative analyses examined barrier differences across sociodemographic groups.

RESULTS

All adolescents (aged 11-17 years, 50% racially minoritized youth, 15% gender diverse youth, 64% LGBTQ + youth; 78% with clinically elevated depressive symptoms) reported at least one barrier to accessing mental health support, and 20% reported multiple barriers. Content analysis revealed 13 barrier categories, with parent-related barriers (three different categories) accounting for 32% of all barriers. The most common barrier categories related to personal and financial constraints. Asian adolescents, adolescents who were aged 17 years or more, and adolescents who reported uncertainty of their gender identity endorsed the numerically highest mean number of barriers to accessing mental health support.

DISCUSSION

High-symptom adolescents reported myriad barriers to accessing mental health support, with 32% of all barriers related to parents.

Real Change or Performative Anti-Racism? Clinical Psychology Programs' Efforts to Recruit and Retain BIPOC Scholars

OBJECTIVE

This study assessed perceptions of Clinical Psychology doctoral programs' efforts to recruit and retain faculty and graduate students of color, as well as differences in perceptions based on participants' position within their program (i.e. graduate student versus faculty) and race.

METHOD

Participants (n = 297; 35% people of color; 79% female; mean age: 32) were graduate students and faculty from Clinical Psychology doctoral programs who completed an anonymous online survey about their programs' efforts to recruit and retain graduate students and faculty of color; sense of belonging and perceptions of racial discrimination within programs; and experiences of cultural taxation and racism within programs.

RESULTS

Faculty (n = 95) reported significantly greater perceptions of recruitment and retention efforts and fewer perceptions of racial discrimination than did graduate students (n = 202). Asian (n = 31), Black (n = 25), and Latinx (n = 35) participants reported significantly fewer perceptions of recruitment and retention efforts, less sense of belonging, and greater perceptions of racial discrimination than did White participants (n = 192). Cultural taxation was common among participants of color, and approximately half (47%) reported they have considered leaving academia - and approximately one third (31%) have considered leaving their program - due to experiences of racism in their program or field.

CONCLUSIONS

Cultural taxation and racial discrimination were common among scholars of color in this sample. Whether intentional or not, these experiences contribute to racially-toxic environments and negatively impact the racial diversity of the mental health workforce.

Substance use severity as a predictor for receiving medication for opioid use disorder among adolescents: An analysis of the 2019 TEDS

BACKGROUND

Medication for opioid use disorder (MOUD) is vastly underutilized in adolescents. Existing treatment guidelines for OUD largely focus on adults, providing limited guidance for pediatric populations. Limited information is known about use of MOUD in adolescents based on substance use severity.

METHODS

This secondary data analysis examined how patient-level variables influenced the receipt of MOUD in adolescents aged 12-17 (n = 1866) using the Treatment Episode Data Set (TEDS) 2019 Discharge data set. A crosstabulation and chi-square statistic evaluated the relationship between a proxy for clinical need based on high-risk opioid use (either reporting daily opioid use within the past 30 days and/or history of injection opioid use) for MOUD in states with and without adolescents receiving MOUD (n = 1071). A two-step logistic regression analysis in states with any adolescents receiving MOUD examined the explanatory power of demographic, treatment intake, and substance use characteristics.

RESULTS

Completion of 12th grade, a GED, or beyond, decreased the likelihood of receiving MOUD (odds ratio [OR]= 0.38, p = 0.017), as did being female (OR = 0.47, p = .006). None of the remaining clinical criteria were significantly associated with MOUD, although a history of one or more arrests increased the likelihood of MOUD (OR = 6.98, p = 0.06). Only 13% of individuals who met criteria for clinical need received MOUD.

CONCLUSIONS

Lower education could serve as a proxy for substance use severity. Guidelines and best practices are needed to ensure the proper distribution of MOUD to adolescents based on clinical need.

Substance use outcomes among individuals with severe mental illnesses receiving assertive community treatment: A systematic review

Assertive Community Treatment (ACT) is a multidisciplinary treatment approach to support people with severe mental illnesses (SMI) in their recovery. While the majority of ACT recipients report co-morbid substance use issues, limited reviews have evaluated the impact of receiving ACT services on substance use outcomes. The purpose of this systematic review was to evaluate the impact of ACT involvement on substance use outcomes among people with SMI. A systematic literature search was conducted including articles published prior to April 2021. Twenty-nine studies were included in this review. Of them, 15 studies implemented a controlled design (six studies demonstrated high quality) and 14 studies implemented a cohort design. From a synthesis of the reviewed studies, five areas of changes associated with substance use emerged including reduced alcohol and drug use severity, lower prevalence of alcohol and drug use, increased stage of change in substance use treatment, and fewer days of hospitalization and intoxication. Thus, future studies should examine the integration of substance use treatment services as part of ACT interventions for opportunities to enhance recovery outcomes among individuals with SMI.

Black girls and referrals: racial and gender disparities in self-reported referral to substance use disorder assessment among justice-involved children

Background

There is a higher prevalence of substance use disorder (SUD) among justice-involved children (JIC). It is critical to ensure that JIC who report current use are referred for SUD assessment and potentially life-saving treatment services. Prior research suggests that certain minoritized groups may be less likely to have ever been referred for screening, and research on intersectionality suggests that these disparities may be exacerbated for racially minoritized females.

Methods

Multivariate logistic regression and interaction effects were employed to analyze longitudinal data from the Florida Department of Juvenile Justice on 12,128 JIC who reported SU in the past 6 months. The main and interaction effects of race and gender on the odds of having a history of reporting a referral to SUD assessment were tested. The primary outcome variable was a self-reported measure of a youth’s history of being referred to service. The control variables included substance type, household income, current SU problems, history of mental health problems, number of misdemeanors, risk to recidivate, and age at first offense.

Results

There were no significant differences in the likelihood of having a history of reporting being referred to SUD assessment between White females, White males, and Latinx females. However, Black females (AOR = 0.62), Latinx males (AOR = 0.71), and Black males (AOR = 0.65) were significantly less likely to self-report having a history of being referred than White males. Black females were 34% likely to report a history of being referred as White males and females.

Conclusion

In this sample, Black females who use substances were substantially less likely to self-report being referred to SUD screening. According to officials, FLDJJ has solid process to ensure referrals are made. Therefore, the results are likely to be due to external factors and alternative explanations. Community leaders and stakeholders may consider culturally relevant and gender-sensitive programs to expand access to services for minoritized adolescents in their communities, schools, and other institutions.

Language Ability Accounts for Ethnic Difference in Mathematics Achievement

The mathematics achievement of minority students has always been a focal point of educators in China. This study investigated the differences in mathematics achievement between Han and minority pupils to determine if there is any cognitive mechanism that can account for the discrepancy. We recruited 236 Han students and 272 minority students (including Uygur and Kazak) from the same primary schools. They were tested on mathematics achievement, language abilities, and general cognitive abilities. The results showed that Han pupils had better mathematics achievement scores and better Chinese language ability than minority students. After controlling for age, gender, and general cognitive abilities, there were still significant differences in mathematics achievement between Han and minority students. However, these differences disappeared after controlling for language ability. These results suggest that the relatively poor levels of mathematics achievement observed in minority students is related to poor Chinese language skills.

Improving Substance Use Prevention, Assessment, and Treatment Financing to Enhance Equity and Improve Outcomes Among Children, Adolescents, and Young Adults

Access to timely prevention and treatment services remains challenging for many children, adolescents, young adults, and families affected by substance use. The American Academy of Pediatrics recognizes the scope and urgency of this problem and has developed this policy statement for consideration by Congress, federal and state policy makers, and public and private payers. This policy statement updates the 2001 policy statement "Improving Substance Abuse Prevention, Assessment, and Treatment Financing for Children and Adolescents" and provides recommendations for financing substance use prevention, assessment, and treatment of children, adolescents, and young adults.

Mutual-help group participation for substance use problems in the US: Correlates and trends from 2002 to 2018

BACKGROUND

Mutual-help groups (MHGs) are an integral component of the substance use disorder (SUD) treatment system in the U.S., and growing evidence suggests that they are effective and cost-effective for SUD-related problems. However, not much is known about the MHG participation patterns in the U.S.

METHODS

Using the 2002-2018 National Survey on Drug Use and Health data, we estimated the annual participation rates and examined the psycho-social-behavioral correlates of MHG participation using logistic regression.

RESULTS

There was no significant linear trend of MHG participation in the total US adult population between 2002 and 2018 (AOR = 0.999, 95% CI = 0.991-1.007). Among adults with past-year SUD, 4.8-7.4% of men and 4.4-6.7% of women participated in MHGs. MHG participants were more likely to be middle-aged (vs. young adults), lower education (less than high school, high school, some college vs. college or higher), lower income (annual household income <$20,000, $20,000-39,999 vs. $75,000 + ), be unemployed or not in the labor force (vs. employed), and were less likely to be Black/African American (vs. White American) and have lower English proficiency (speak English not well/not at all vs. very well/well),.

CONCLUSION

MHG participation rates have remained relatively stable over the past two decades. MHGs were utilized more by individuals with lower socioeconomic status indicators and more criminal/legal involvement, possibly due to MHGs' free accessibility. However, research is needed to understand why young adults, Black, and individuals with lower English proficiency are somewhat less likely to attend MHGs.

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.

Polydrug Use and Dating Violence Among Emerging Adults

We examined sociodemographic and psychosocial risk factors that moderate the (poly) substance use and dating violence victimization and perpetration relationship among emerging adults. Using an ethnically diverse sample (N = 698), we used latent class analyses to identify mutually exclusive groups based on monthly and past-year substance use. We then examined these groups as they relate to dating violence victimization and perpetration and the moderating effect of various risk factors. Five classes were identified based on substance use patterns: (a) Regular Alcohol use, (b) Polysubstance use, (c) Heavy Alcohol and Marijuana use, (d) Mild Alcohol use, and (e) Occasional Alcohol and Marijuana use classes. Participants in the Polysubstance use class were the most likely to perpetrate dating violence followed by Heavy Alcohol and Marijuana use, Occasional Alcohol and Marijuana use, Regular Alcohol, and Mild Alcohol use classes. Similarly, participants in the Polysubstance use class were the most likely to be victims of dating violence followed by Occasional Alcohol and Marijuana, Heavy Alcohol and Marijuana, Regular Alcohol, and Mild Alcohol use classes. Depending on substance use class, gender, ethnicity, socioeconomic status, history of dating violence, and trauma symptoms differentially influenced dating violence perpetration and victimization at 1-year follow-up. Our findings support the need to comprehensively address dating violence among emerging adults. Intimate partner violence prevention and intervention programs may benefit from targeting emerging adults who misuse substances and incorporating substance use interventions into dating violence prevention efforts.

A modified measurement-based care approach to improve mental health treatment engagement among racial and ethnic minoritized youth

Despite high levels of need, racial and ethnic minoritized (REM) youth are much less likely than their White peers to engage in mental health treatment. Concerns about treatment relevance and acceptability and poor therapeutic alliance have been shown to impact treatment engagement, particularly retention, among REM youth and families. Measurement-based care (MBC) is a client-centered practice of collecting and using client-reported progress data throughout treatment to inform shared decision-making. MBC has been associated with increased client involvement in treatment, improved client-provider communication, and increased satisfaction with treatment services. Despite its promise as a treatment engagement strategy, MBC has not been studied in this capacity with REM youth or systematically modified to address the needs of culturally-diverse populations. In this article, we propose a culturally-modified version of MBC, Strategic Treatment Assessment with Youth (STAY), to improve treatment engagement among REM youth and families. Specifically, STAY is designed to target perceptual barriers to treatment to improve treatment retention and ultimately, client outcomes. The four STAY components (i.e., Introduce, Collect, Share, and Act) are based on an existing MBC practice framework and modified to address perceptual barriers to treatment among REM youth. The clinical application of this model is presented via a case example. Finally, future research directions to explore the use of MBC as a treatment retention strategy with REM client populations are provided. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Monthly Trends in Drug Overdose Mortality among Youth Aged 15-34 Years in the United States, 2018-2021: Measuring the Impact of the COVID-19 Pandemic

BACKGROUND

Adolescents and young adults in the United States (US) have experienced a significant increase in drug overdose mortality rates in the last two decades. During the Coronavirus disease 2019 (COVID-19) pandemic, they experienced a lack of access to substance use disorder treatment, stay-home orders, school closure, social isolation, increased psychological distress, and financial strain. Few studies have examined the impact of the pandemic on monthly trends in drug-overdose mortality among youth by race/ethnicity. This study estimates differential changes in monthly drug overdose mortality among youth in the US by age, sex, and race/ethnicity.

METHODS

Monthly deaths from the final 2018-2020 national mortality data and the 2021 provisional mortality data were used, and monthly population estimates were obtained from the Census Bureau. We calculated age-specific monthly drug overdose deaths per one million population and used log-linear regression models to estimate monthly percent increases in mortality rates from January 2018 through October 2021.

RESULTS

Drug-overdose deaths among individuals aged 15-34 increased by 36.5% from 2019 (21,152 deaths) to 2020 (28,879 deaths). From February 2020 to May 2020, the drug-overdose mortality rate increased by 62% for males, 53% for females, 79% for Blacks, 62% for American Indians/Alaska Natives (AIANs), 57% for Hispanics, 56% for non-Hispanic Whites, and 47% for Asians. From January 2018 to October 2021, the average monthly drug-overdose mortality rate increased by 2.69% per month for Blacks, 2.54% for AIANs, 2.27% for Hispanics, 1.37% for Asians, and 0.81% for non-Hispanic Whites. Increases in drug-overdose mortality were more rapid among males than females and among youth aged 15-24 than youth aged 25-34.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

During the peak months in 2020 and 2021, the COVID-19 pandemic had a disproportionate impact by race/ethnicity on trends in drug overdose mortality among the youth. Drug overdose mortality rates increased faster among Blacks, Hispanics, AIANs, and Asians compared to non-Hispanic Whites.

Addressing adolescent substance use in an urban pediatric federally qualified health center

OBJECTIVE

Screening, brief intervention, and referral to treatment (SBIRT) is a systematic approach to identification and intervention for individuals at risk for substance use disorders. Prior research indicates that SBIRT is underutilized in pediatric primary care. Yet few studies have examined procedures for identifying and addressing substance use in clinics that serve publicly insured adolescents (i.e., federally qualified health centers [FQHC]). This descriptive, multi-method study assessed adolescent substance use frequency and provider perspectives to inform SBIRT implementation in an urban pediatric FQHC in California.

METHODS

A medical record review assessed substance use frequency and correlates among publicly insured adolescents aged 12-17 years who completed a well-child visit in pediatric primary care between 2014 and 2017 (N = 2252). Data on substance use (i.e., alcohol, illicit drugs, and tobacco) were from a health assessment tool mandated by Medicaid. Semi-structured interviews with 12 providers (i.e., pediatricians, nurse practitioners, behavioral health clinicians) elicited information about the current clinic workflow for adolescent substance use and barriers and facilitators to SBIRT implementation.

RESULTS

Of 1588 adolescents who completed the assessment (70.5%), 6.8% reported current substance use. Self-reported use was highest among non-Hispanic Black (15.2%) adolescents and those with co-occurring depressive symptoms (14.4%). Provider-reported challenges to implementing SBIRT included a lack of space for confidential screening and a lack of referral options. Providers favored implementing technology-based tools such as tablets for adolescent pre-visit screening and electronic medical record-based decision support to facilitate brief intervention and treatment referrals.

CONCLUSIONS

This study fills a substantial research gap by examining factors that impede and support SBIRT implementation in pediatric FQHC settings. Successful SBIRT implementation in these settings could significantly reduce the unmet need for substance use treatment among uninsured and publicly insured adolescents. Pediatric primary care and urgent care providers perceived SBIRT to be feasible, and health information and digital technologies may facilitate the integration of SBIRT into clinic workflows. Ensuring confidentiality for screening and expanding referral options for adolescents in need of community-based addiction treatment are also critical to increasing SBIRT uptake.

Underrepresentation of diverse populations and clinical characterization in opioid agonist treatment research: A systematic review of the neurocognitive effects of buprenorphine and methadone treatment

INTRODUCTION

The relative neurocognitive effects of the two most common opioid agonist treatments (OAT; buprenorphine and methadone) for opioid use disorder (OUD) are poorly understood. The aim of this systematic review is to examine the neurocognitive effects of OAT (buprenorphine and methadone) and the clinical and sociodemographic characteristics of study samples.

METHODS

The research team queried PubMed, PsycINFO and Cochrane Reviews for articles (01/1980-01/2020) with terms related to neurocognitive testing in adults (age ≥ 18) prescribed OAT. The team extracted neurocognitive data and grouped them by domain (e.g., executive functioning, learning/memory), and assessed study quality.

RESULTS

The search retrieved 2341 abstracts, the team reviewed 278 full articles, and 32 met inclusion criteria. Of these, 31 were observational designs and one was an experimental design. Healthy controls performed better across neurocognitive domains than OAT-treated persons (buprenorphine or methadone). Compared to those with active OUD, OAT-treated persons had better neurocognition in various domains. However, in seven studies comparing buprenorphine- and methadone-treated persons, buprenorphine was associated with better neurocognition than was methadone, with moderate to large effect sizes in executive functioning, attention/working memory, and learning/memory. Additionally, OAT research underreports clinical characteristics and underrepresents Black and Latinx adults, as well as women.

CONCLUSIONS

Findings suggest that compared to active opioid use, both buprenorphine and methadone treatment are associated with better neurocognitive functioning, but buprenorphine is associated with better executive functioning, attention/working memory, and learning/memory. These findings should be interpreted with caution given widespread methodological heterogeneity, and limited representation of ethnoracially diverse adults and women. Rigorous longitudinal comparisons with more diverse, better characterized samples will help to inform treatment and policy recommendations for persons with OUD.

Utilization of substance use treatment among criminal justice-involved individuals in the United States

Over six million individuals are involved with the criminal justice system in the United States, of which a large proportion report extensive substance use. We examined the extent to which criminal justice-involvement affects substance use treatment utilization among participants from one of the largest annual surveys on substance use in the U.S., the National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression analyses indicated that criminal justice involvement was significantly associated with receiving substance use treatment in the past year (AOR 8.00, 95% CI: 6.23-10.27, p < 0.001). However, those with criminal justice histories continue to face barriers to treatment. Among individuals ages 12 and older who reported past year criminal justice involvement and met criteria for a substance use disorder, 18.9% reported receiving past year substance use treatment. After controlling for key demographic and drug use characteristics in a multivariable logistic regression model, Black criminal justice involved Americans were somewhat less likely to report receiving substance use treatment in the past year compared to White criminal justice involved Americans, although the association was not significant (AOR 0.87, 95% CI 0.58-1.29, p = 0.481). Treatment programs targeted to increase minority engagement and address persistent barriers to substance use treatment may be valuable for curbing substance use and recidivism among criminal justice-involved individuals.

Racial/Ethnic Disparities in Mutual Help Group Participation for Substance Use Problems

Mutual help groups are a ubiquitous component of the substance abuse treatment system in the United States, showing demonstrated effectiveness as a treatment adjunct; so, it is paramount to understand whether they are as appealing to, and as effective for, racial or ethnic minority groups as they are for Whites. Nonetheless, no known comprehensive reviews have examined whether there are racial/ethnic disparities in mutual help group participation. Accordingly, this study comprehensively reviewed the U.S. literature on racial/ethnic disparities in mutual help participation among adults and adolescents with substance use disorder treatment need. The study identified 19 articles comparing mutual help participation across specific racial/ethnic minority groups and Whites, including eight national epidemiological studies and 11 treatment/community studies. Most compared Latinx and/or Black adults to White adults, and all but two analyzed 12-step participation, with others examining "self-help" attendance. Across studies, racial/ethnic comparisons yielded mostly null (N = 17) and mixed (N = 9) effects, though some findings were consistent with a racial/ethnic disparity (N = 6) or minority advantage (N = 3). Findings were weakly suggestive of disparities for Latinx populations (especially immigrants, women, and adolescents) as well as for Black women and adolescents. Overall, data were sparse, inconsistent, and dated, highlighting the need for additional studies in this area.

Measurement-Based Care in the Treatment of Adolescents with Substance Use Disorders

Measurement-based care in adolescent substance use is an important element of the evidence-based framework of Screening, Brief Intervention, and Referral to Treatment (SBIRT). Use of a validated measure for detecting substance use, misuse, and substance use disorders is significantly more effective than the use of unvalidated tools or clinician intuition. There are now a variety of established and new validated screening tools that are available for use with adolescents and that capture the range of adolescent substance use behaviors. This area, however, continues to evolve rapidly.

Barriers, facilitators, and disparities in retention for adolescents in treatment for substance use disorders: a qualitative study with treatment providers

BACKGROUND

Retention in substance use treatment is one of the strongest predictors of improved outcomes among adolescents, making retention an important goal of treatment. We examined treatment providers' perspectives on barriers and facilitators to treatment retention among adolescents, and their views on contributors to racial/ethnic disparities in retention including ways to address disparities.

METHODS

Semi-structured interviews were conducted with 19 providers at state-licensed detoxification, residential, and outpatient facilities serving adolescents for substance use disorders in Massachusetts. Interviews were coded by at least two independent coders.

RESULTS

Providers identified barriers and facilitators at the policy/systems, facility, family, and client levels. Some of the barriers included insurance limits on sessions/length of stay and low reimbursement (policy/systems), staff turnover (facility), low family engagement (family), and low internal motivation (client). Some facilitators mentioned were support from state's substance use agency (policy/systems), flexibility with meeting location (facility), family participation (family), and high internal motivation and presence of external motivators (client). Barriers that contributed to racial/ethnic disparities included lower socio-economic status, language barriers, and mistrust. Having bilingual/bicultural staff and multi-lingual materials, and facilitating transportation were identified as strategies for reducing disparities in treatment retention.

CONCLUSIONS

It is critical that adolescents who access substance use services remain and complete treatment and that there is equity in treatment retention. Provider perspectives in factors associated with retention can inform the development of comprehensive interventions and policies to help improve retention and reduce disparities.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

BACKGROUND

Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment?

METHODS

To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components.

RESULTS

We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions.

CONCLUSION

While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

Alcohol Use Disorders in Adolescents

Alcohol use during adolescence is an important and modifiable health risk behavior given the significant acute consequences and long-term impacts on the developing brain. Alcohol is the most common substance used by young adults 12 to 17 years old, with binge drinking, polysubstance use, and co-occurring mental health disorders posing particular concerns in this age group. Physicians can play a crucial role in screening and responding to alcohol use, with targeted brief interventions designed to delay or decrease use.

Treatment outcome disparities for opioid users: Are there racial and ethnic differences in treatment completion across large US metropolitan areas?

BACKGROUND

The present study examined racial/ethnic disparities in initial treatment episode completion for adult clients reporting opioids as their primary problem substance in large US metropolitan areas.

METHODS

Data were extracted from the 2013 TEDS-D dataset (Treatment Episode Dataset-Discharge) for the 42 largest US metropolitan statistical areas (MSAs). Fixed effects logistic regression controlling for MSA was used to estimate the effect of race/ethnicity on the likelihood of treatment completion. The model was repeated for each individual MSA in a stratified design to compare the geographic variation in racial/ethnic disparities, controlling for gender, age, education, employment, living arrangement, treatment setting, medication-assisted treatment, referral source, route of administration, and number of substances used at admission.

RESULTS

Only 28% of clients completed treatment, and the results from the fixed effects model indicate that blacks and Hispanics are less likely to complete treatment compared to whites. However, the stratified analysis of individual MSAs found only three of the 42 MSAs had racial/ethnic disparities in treatment completion, with the New York City (NYC) MSA largely responsible for the disparities in the combined sample. Supplementary analyses suggest that there are greater differences between whites and minority clients in the NYC MSA vs. other cities on characteristics associated with treatment completion (e.g., residential treatment setting).

CONCLUSION

This study underscores the need for improving treatment retention for all opioid using clients in large metropolitan areas in the US, particularly for minority clients in those localities where disparities exist, and for better understanding the geographic context for treatment outcomes.

Understanding barriers to specialty substance abuse treatment among Latinos

BACKGROUND

National studies have documented that Latinos are less likely to use specialty substance abuse treatment (e.g., rehabilitation programs, in/out-patient services) than other racial/ethnic groups. Disparities in treatment utilization are particularly pronounced between Latinos and Whites. Few national studies have explicitly examined barriers to treatment by race/ethnicity, and current results are inconclusive. The purpose of this study was to gain a better understanding of barriers to specialty substance abuse treatment among Latinos.

METHODS

In 2017-2018, in-depth qualitative interviews were conducted with 54 White, Black, and Latino participants who met eligibility criteria for a recent substance use disorder. Participants were recruited via online ads and screened for eligibility through an online survey. Interview questions were grounded in the Theory of Planned Behavior (TBP): Participants were asked about treatment-related barriers in the domains of attitudes, subjective norms, and perceived control. Interviews were transcribed verbatim and coded by two independent coders. Barriers were compared across all interviews and by race/ethnicity.

RESULTS

Latinos were significantly more likely to report attitudinal and subjective norm barriers than their White and Black counterparts. Within the attitudes domain, results suggested that Latinos largely avoided specialty treatment due to barriers stemming from cultural factors, perceived treatment efficacy, recovery goals, and perceived treatment need. In the area of subjective norms, stigma and perceived lack of social support from family were more pervasive among Latinos' narratives. Lastly, in terms of perceived control, a minority of Latinos reported logistical barriers to treatment.

CONCLUSION

Specialty substance abuse treatment services have been found to be effective regardless of race/ethnicity. Understanding why Latinos use specialty treatment at low rates is key to reducing existing racial/ethnic disparities related to substance abuse. This study identified several malleable barriers that interventions can target to increase Latinos' utilization of treatment. These barriers may also be key to explaining Latino-White disparities in treatment utilization.

Prevalence of Mental Disorder and Service Use by Immigrant Generation and Race/Ethnicity Among U.S. Adolescents

OBJECTIVE

To examine differences in lifetime prevalence of mental disorder and service use among U.S. adolescents by both immigrant generation and race/ethnicity.

METHOD

A total of 6,250 adolescents aged 13 to 18 years in the National Comorbidity Survey Replication Adolescent Supplement were assessed for lifetime prevalence of mood and/or anxiety disorders, behavior disorders, and mental health service use. Twelve groups defined by self-identified race/ethnicity (non-Hispanic white, Hispanic, non-Hispanic black, Asian) and immigrant generation (first, second, third, or more) were compared.

RESULTS

Differences in prevalence of lifetime mental disorder were most apparent when immigrant generation and race/ethnicity were considered jointly. Compared to third+generation non-Hispanic white adolescents, the odds of mood/anxiety disorder were increased among second-generation Asian (adjusted odds ratio [AOR] = 2.51; 95% CI = 1.22-5.17) and third+generation Hispanic (AOR = 1.28; 95% CI = 1.00-1.63) but reduced among first-generation Asian (AOR = 0.27; 95% CI = 0.10-0.71) and second-generation non-Hispanic white adolescents (AOR = 0.50; 95% CI = 0.30-0.81). The odds of behavior disorder were lower among first-generation Asian (AOR = 0.26; 95% CI = 0.09-0.71) and all generations of non-Hispanic black adolescents (AOR range 0.43-0.55). Adjusting for lifetime disorder, first-generation Hispanic and non-Hispanic white adolescents and all generations of non-Hispanic black adolescents were less likely to receive mental health services (AOR range 0.24-0.55).

CONCLUSIONS

Variation in risk of disorder by immigrant generation and race/ethnicity underscores the importance of considering social, economic, and cultural influences in etiologic and treatment studies of adolescent psychopathology. Lower rates of service use, particularly among first-generation immigrant adolescents, highlight the need to identify and address barriers to recognition and treatment of mental disorders among adolescents from immigrant and racial/ethnic minority backgrounds.

U.S. adolescent alcohol use by race/ethnicity: Consumption and perceived need to reduce/stop use

Understanding racial/ethnic drinking patterns and service provision preferences is critical for deciding how best to use limited alcohol prevention, intervention, and treatment resources. We used nationally representative data from 150,727 U.S. high school seniors from 2005 to 2016 to examine differences in a range of alcohol use behaviors and the felt need to reduce or stop alcohol use based on detailed racial/ethnic categories, both before and after controlling for key risk/protective factors. Native students reported particularly high use but corresponding high felt need to reduce/stop use. White and dual-endorsement students reported high use but low felt need to stop/reduce alcohol use.

Exercise in the Treatment of Youth Substance Use Disorders: Review and Recommendations

Substance use disorders among youth represent a significant public health concern. It is well established that regular exercise provides important physical and mental health benefits; however, evidence for the role of exercise as an adjunct component within substance use disorder treatment is scarce. In this review, we identify factors associated with the development and persistence of substance use disorders among youth, identify current treatment modalities, and present evidence to support the efficacy of incorporating exercise participation during rehabilitation. We also provide a series of recommendations for future research that explores the feasibility and effectiveness of exercise participation as a complement to substance use disorder treatment among youth.

Marijuana Use, Recent Marijuana Initiation, and Progression to Marijuana Use Disorder Among Young Male and Female Adolescents Aged 12-14 Living in US Households

Marijuana initiation during adolescence, and early adolescence in particular, is associated with adverse health consequences. Our study used 2005–2014 data from the annual, cross-sectional National Survey on Drug Use and Health to study the prevalence and correlates of marijuana initiation, use, and marijuana use disorder (MUD; abuse or dependence) among 12- to 14-year olds living in civilian US households (n = 84 954). Examined correlates included age, sex, race/ethnicity, poverty status, metropolitan status, year of survey, depression, tobacco use, alcohol use, and fighting at school. Sex differences in the correlates of lifetime use and past year marijuana initiation were tested via interaction. Lifetime prevalence of marijuana use was 5.5%; 3.2% reported past year initiation. About 1 in 6 (16.8%) past year initiates progressed to MUD within 12 months of first use. Although men had higher prevalence of lifetime use than women, past year initiation did not differ by sex. On examining the sex*race/ethnicity interaction effects, findings determined that non-Hispanic black and Hispanic men had higher prevalence estimates of ever using marijuana and incidence of past year initiation as compared with non-Hispanic white men; these race/ethnicity differences were not found among women. Identifying correlates of initiation and progression to MUD among young adolescents is critical to improve prevention and treatment program targets.

Socioeconomic differences in adolescent substance abuse treatment participation and long-term outcomes

Socioeconomic status (SES) has been consistently linked to poorer access, utilization and outcomes of health care services, but this relationship has been understudied in adolescent substance abuse treatment research. This study examined SES differences in adolescent's treatment participation and long-term outcomes of abstinence and 12-step attendance over five years after treatment. Data are from 358 adolescents (ages 13-18) who were recruited at intake to substance abuse treatment between 2000 and 2002 at four Kaiser Permanente Northern California outpatient treatment programs. Follow-up interviews of adolescents and their parents were conducted at 1, 3, and 5years, with over 80% response rates across time points. Using parent SES as a proxy for adolescent SES, no socioeconomic differences were found in treatment initiation, treatment retention, or long-term abstinence from alcohol or drugs. Parent education, but not parent income, was significantly associated with 12-step attendance post-treatment such that adolescents with higher parent education were more likely to attend than those with lower parent education. Findings suggest a lack of socioeconomic disparities in substance abuse treatment participation in adolescence, but potential disparities in post-treatment 12-step attendance during the transition from adolescence to young adulthood.

The Impact of Single Mothers' Health Insurance Coverage on Behavioral Health Services Utilization by Their Adolescent Children

Adolescents living in single-mother households are more likely to have behavioral health conditions, but are less likely to utilize any behavioral health services. Using nationally representative mother-child pair data pooled over 6 years from the National Survey on Drug Use and Health, the study finds that when single mothers were uninsured, their adolescent children were less likely to utilize any behavioral health services, even when the children themselves were covered by insurance. The extension of health coverage under the Affordable Care Act (ACA) to uninsured single mothers could improve the behavioral health of the adolescent population.

Cell phone-based ecological momentary assessment of substance use context for Latino youth in outpatient treatment: Who, what, when and where

BACKGROUND

Relationships between alcohol, marijuana and other drug (AOD) use and contextual factors have mostly been established through retrospective self-report. Given the embeddedness of cell phones in adolescents' daily activities, cell phone-based ecological momentary assessment (CEMA) provides an opportunity to better understand AOD use in youth and how cell phones can be used to self-monitor and deliver interventions. We use CEMA to examine AOD use in Latino youth who have been especially understudied.

METHODS

Twenty-eight mostly Latino youth (ages 13-18) in outpatient substance abuse treatment recorded AOD use, contextual factors, cravings, and affect through once-daily CEMA over one month periods. Random-effects logistic regression was used to compare contextual factors between periods of AOD use and non-use.

RESULTS

The most frequent contextual factors reported during AOD use were being with close friends and "hanging out" as the primary activity. During AOD use compared to non-use, youth were more likely to be with close friends (OR=4.76; p<0.01), around users (OR=17.69; p<0.01), and at a friend's house (OR=5.97; p<0.01). Alcohol use was more frequently reported at night (63% vs 34%) and on weekends relative to other substances (64% vs 49%). Strong cravings were more frequently reported on AOD-use days (OR=7.34; p<0.01). Types of positive and negative affect were reported with similar frequencies, regardless of AOD use.

CONCLUSIONS

Reporting on social context, location, day and time of day, and cravings all show promise in developing cell phone-based interventions triggered by contextual data.

Ethnic and racial differences in mental health service utilization for suicidal ideation and behavior in a nationally representative sample of adolescents

BACKGROUND

This study examined racial/ethnic differences in mental health treatment utilization for suicidal ideation and behavior in a nationally representative sample of adolescents.

METHOD

Data were drawn from the National Survey on Drug Use and Health. Participants included 4176 depressed adolescents with suicidal ideation and behavior in the previous year. Weighted logistic regressions were estimated to examine whether adolescent racial/ethnic minorities had lower rates of past-year treatment for suicidal ideation and behavior in inpatient or outpatient settings, while adjusting for age, depressive symptom severity, family income, and health insurance status.

RESULTS

Among adolescents with any suicidal ideation and behavior, and suicide attempts specifically, non-Hispanic blacks and Native Americans were less likely than whites to receive outpatient treatment, and multiracial adolescents were less likely to be admitted to inpatient facilities. Apart from Hispanics, racial/ethnic minorities were generally less likely to receive mental health care for suicidal ideation, particularly within psychiatric outpatient settings. A pattern emerged with racial/ethnic differences in treatment receipt being greatest for adolescents with the least severe suicidal ideation and behavior.

LIMITATIONS

The cross-sectional data limits our ability to form causal inferences.

CONCLUSION

Strikingly low rates of treatment utilization for suicidal ideation and behavior were observed across all racial/ethnic groups. Certain racial/ethnic minorities may be less likely to seek treatment for suicidal ideation and behavior when symptoms are less severe, with this gap in treatment use narrowing as symptom severity increases. Native Americans were among the racial/ethnic groups with lowest treatment utilization, but also among the highest for rates of suicide attempts, highlighting the pressing need for strategies to increase mental health service use in this particularly vulnerable population.

Treatment Utilization Among Adolescent Substance Users: Findings from the 2002 to 2013 National Survey on Drug Use and Health

BACKGROUND

Adolescent substance users face serious health and social consequences and benefit from early diagnosis and treatment. The objectives of this study were to observe trends in treatment utilization; examine correlates of treatment utilization and treatment types/settings among adolescent substance users with and without substance use disorder (SUD); and assess gender differences.

METHODS

National Survey on Drug Use and Health data were pooled across 2002 to 2013, with a combined sample of 79,885 past-year substance users ages 12 to 17 (17,510 with SUD and 62,375 without SUD). Treatment was defined as receiving treatment or counseling for use of alcohol or any drug, not counting cigarettes. Trends were assessed by joinpoint linear regression, and multivariable logistic regression assessed odds ratios of treatment utilization.

RESULTS

Percentages of past-year treatment use did not change in 2002 to 2013. Treatment utilization was more prevalent among adolescents with SUD than without (11.4% vs. 1.4%) and among males than females. Among adolescents with and without SUD, criminal justice involvement and perceiving a need for treatment increased adolescent treatment utilization, while SUDs other than alcohol abuse, older age, and talking to parents increased treatment use among adolescents with SUD, and polysubstance use and male gender increased treatment among those without SUD. Treatment gaps persisted among non-Hispanic Blacks for both groups with and without SUD, male Hispanics with SUD, female non-Hispanic Asians without SUD, and private insurance coverages. Gender differences were observed in SUD, race/ethnicity, and insurance coverage. Most adolescents received treatment for both alcohol and drug use, and self-help group and outpatient rehabilitation facility were the most used treatment settings.

CONCLUSIONS

Treatment utilization among adolescents with past-year substance use remained low and unimproved in 2002 to 2013. Treatment gaps among minority populations, insurance coverage, and in educating adolescents on seeking relevant treatment must be addressed. Using screening processes such as Screening, Brief Intervention, and Referral to Treatment, health professionals can help prevent lifelong SUD by recognizing and addressing substance misuse early.

Polysubstance Use among Minority Adolescent Males Incarcerated for Serious Offenses

BACKGROUND

Adolescent juvenile offenders are at high risk for problems associated with drug use, including polysubstance use (i.e., use of a variety of drugs). The combination of juvenile offending and polysubstance use presents a significant public and child health concern.

OBJECTIVE

This study explored polysubstance use among a sample of youth incarcerated for serious offenses. We examined several risk factors for substance use and delinquency (i.e., early and frequent substance use, prior history of arrests, school expulsion, Black ethnicity), as well as the association between aggression and polysubstance use.

METHODS

Data were collected via questionnaires from 373 serious male juvenile offenders upon intake into a secure locked facility. Youth were on average 16 years old, and minority youth were overrepresented (28.1% Black, 53.1% Latino). Poisson regressions were used to assess the associations between the risk factors, aggression, and polysubstance use.

RESULTS

Consistent with the literature, Black youth reported less polysubstance use and later age of drug use onset than White and Latino youth. Findings suggest that Latino juvenile offenders and those with an early and problematic pattern of substance use are at heightened risk for polysubstance use. Aggression was not significantly related to polysubstance use, over and above the risk factors.

CONCLUSIONS

Given that Latino youth experience low rates of treatment for substance use, the development of culturally-sensitive interventions for these youth is needed. Interventions should also be multifaceted to address the multitude of risk factors associated with polysubstance use among juvenile offenders.

Compliance to Cell Phone-Based EMA Among Latino Youth in Outpatient Treatment

Outpatient treatment practices for adolescent substance users utilize retrospective self-report to monitor drug use. Cell phone-based ecological momentary assessment (CEMA) overcomes retrospective self-report biases and can enhance outpatient treatment, particularly among Latino adolescents, who have been understudied with regard to CEMA. This study explores compliance to text message-based CEMA with youth (n = 28; 93% Latino) in outpatient treatment. Participants were rotated through daily, random, and event-based CEMA strategies for 1-month periods. Overall compliance was high (>80%). Compliance decreased slightly over the study period and was less during random versus daily strategies and on days when alcohol use was retrospectively reported. Findings suggest that CEMA is a viable monitoring tool for Latino youth in outpatient treatment, but further study is needed to determine optimal CEMA strategies, monitoring time periods, and the appropriateness of CEMA for differing levels of substance use.

Substance use disorders and co-morbidities among Asian Americans and Native Hawaiians/Pacific Islanders

BACKGROUND

Asian Americans (AAs) and Native Hawaiians/Pacific Islanders (NHs/PIs) are the fastest growing segments of the US population. However, their population sizes are small, and thus AAs and NHs/PIs are often aggregated into a single racial/ethnic group or omitted from research and health statistics. The groups' substance use disorders (SUDs) and treatment needs have been under-recognized.

METHOD

We examined recent epidemiological data on the extent of alcohol and drug use disorders and the use of treatment services by AAs and NHs/PIs.

RESULTS

NHs/PIs on average were less educated and had lower levels of household income than AAs. Considered as a single group, AAs and NHs/PIs showed a low prevalence of substance use and disorders. Analyses of survey data that compared AAs and NHs/PIs revealed higher prevalences of substance use (alcohol, drugs), depression and delinquency among NHs than among AAs. Among treatment-seeking patients in mental healthcare settings, NHs/PIs had higher prevalences of DSM-IV diagnoses than AAs (alcohol/drug, mood, adjustment, childhood-onset disruptive or impulse-control disorders), although co-morbidity was common in both groups. AAs and NHs/PIs with an SUD were unlikely to use treatment, especially treatment for alcohol problems, and treatment use tended to be related to involvement with the criminal justice system.

CONCLUSIONS

Although available data are limited by small sample sizes of AAs and NHs/PIs, they demonstrate the need to separate AAs and NHs/PIs in health statistics and increase research into substance use and treatment needs for these fast-growing but understudied population groups.

Preliminary findings on the association between clients' perceived helpfulness of substance abuse treatment and outcomes: does race matter?

BACKGROUND

Few studies examine the helpfulness and effectiveness of substance abuse treatment from the clients' perspective.

METHODS

The current secondary analysis examined the perceived helpfulness of substance abuse treatment components and its relationship to treatment outcomes among 387 Black and White adults participating in a multisite randomized clinical trial (RCT) of Motivational Enhancement Therapy. Throughout the 16-week RCT, participants self-reported substance use. Upon completion of treatment, participants completed a self-report measure assessing the perceived helpfulness of treatment components.

RESULTS

Black participants rated 9 out of 12 treatment components (e.g., "learning skills that will help me cope with my problems") as being more helpful than their White counterparts, even after controlling for age, gender, employment status, primary drug type, and treatment assignment. However, perceived helpfulness ratings were not associated with substance use outcomes among Black or White participants.

CONCLUSIONS

Clients' perceived helpfulness of treatment components is an important factor to consider in improving the delivery of substance abuse treatment, especially for Black adults.

Explaining racial/ethnic differences in adolescent substance abuse treatment completion in the United States: a decomposition analysis

PURPOSE

To identify contributors to racial/ethnic differences in completion of alcohol and marijuana treatment among adolescents at publicly funded providers.

METHODS

The 2007 Treatment Episode Data Set provided substance use history, treatment setting, and treatment outcomes for youth aged 12-17 years from five racial/ethnic groups (N = 67,060). Individual-level records were linked to variables measuring the social context and service system characteristics of the metropolitan area. We implemented nonlinear regression decomposition to identify variables that explained minority-white differences.

RESULTS

Black and Hispanic youth were significantly less likely than whites to complete treatment for both alcohol and marijuana. Completion rates were similar for whites, Native Americans, and Asian-Americans, however. Differences in predictor variables explained 12.7% of the black-white alcohol treatment gap and 7.6% of the marijuana treatment gap. In contrast, predictors explained 57.4% of the Hispanic-white alcohol treatment gap and 19.8% of the marijuana treatment gap. While differences in the distribution of individual-level variables explained little of the completion gaps, metropolitan-level variables substantially contributed to Hispanic-white gaps. For example, racial/ethnic composition of the metropolitan area explained 41.0% of the Hispanic-white alcohol completion gap and 23.2% of the marijuana completion gap. Regional differences in addiction treatment financing (particularly use of Medicaid funding) explained 13.7% of the Hispanic-white alcohol completion gap and 9.8% of the Hispanic-white marijuana treatment completion gap.

CONCLUSIONS

Factors related to social context are likely to be important contributors to white-minority differences in addiction treatment completion, particularly for Hispanic youth. Increased Medicaid funding, coupled with culturally tailored services, could be particularly beneficial.

Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States

IMPORTANCE

Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees.

OBJECTIVE

To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure.

DESIGN, SETTING, AND PARTICIPANTS

We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population.

MAIN OUTCOMES AND MEASURES

Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid.

RESULTS

Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME],  -3.1; 95% CI,  -5.2% to -0.9%), rural (-9.2%; -11.1% to -7.4%), and/or uninsured (-9.5%; -13.0% to -5.9%) residents are less likely to have one of these facilities.

CONCLUSIONS AND RELEVANCE

The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.

State parity laws and access to treatment for substance use disorder in the United States: implications for federal parity legislation

IMPORTANCE

The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment.

OBJECTIVE

To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment.

INTERVENTIONS

State-level SUD parity laws during the study period.

MAIN OUTCOMES AND MEASURES

State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance.

RESULTS

The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance.

CONCLUSIONS AND RELEVANCE

We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Health insurance and treatment of adolescents with co-occurring major depression and substance use disorders

OBJECTIVE

The goals of this study were to identify treatment rates among adolescents with co-occurring major depressive episode (MDE) and substance use disorder (SUD), and to examine the role of health insurance in the treatment of these disorders.

METHOD

Seven years of cross-sectional data (2004-2010) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 2,111 adolescents who had both a past-year MDE and SUD and whose insurance status was known. The associations of public and private insurance with MDE and SUD treatment were examined using multinomial logistic regressions that controlled for health status and sociodemographic variables.

RESULTS

Less than one-half (48%) of adolescents received any form of MDE treatment in the past year, and only 10% received any form of SUD treatment. Only 16% of adolescents who received MDE treatment also received SUD treatment. Relative to no insurance, public insurance was associated with an increased likelihood of receiving MDE treatment alone, but not with an increased likelihood of receiving both MDE and SUD treatment. Involvement in the criminal justice system was the major factor affecting the likelihood that an adolescent would receive both MDE and SUD treatment, as opposed to either no treatment or treatment for MDE alone.

CONCLUSIONS

Exceptionally low rates of SUD treatment were observed in this high-risk sample. Study findings highlight a missed opportunity to assess and to treat SUD among adolescents with co-occurring MDE and SUD who have received some form of MDE treatment in the past year.

The role of perceived peer prejudice and teacher discrimination on adolescent substance use: a social determinants approach

Although Black adolescents have reported a lower prevalence of substance use relative to non-Hispanic Whites, Black youth are disproportionately affected by adverse social outcomes. Social scientists have highlighted that using a framework that includes perceived peer prejudice and teacher discrimination as social determinants of adolescent risk behaviors is essential to fully understanding substance use behaviors in adolescents. However, this area of research remains underdeveloped. This study examined whether and to what extent perceived peer prejudice and teacher discrimination affect binge drinking and marijuana use by Black (n = 514) and non-Hispanic White (n = 2,818) adolescents using data from the National Longitudinal Study of Adolescent Health, Wave 2, Public Use dataset. Findings suggest that peer prejudice increased the risk of substance use in non-Hispanic White youth only, whereas experiences of teacher discrimination increased the risk of substance use in both Black and non-Hispanic White youth. The study's limitations are noted, and implications for future research are discussed.

Childhood maltreatment and illicit drug use in middle adulthood: the role of neighborhood characteristics

This paper examined whether childhood maltreatment increases the risk of living in neighborhoods with less desirable characteristics (i.e., more disorder and disadvantage, less social cohesion, social control and advantage, and fewer resources) in middle adulthood and whether these neighborhood characteristics influence subsequent illicit drug use. Using a prospective cohort design study, court documented cases of childhood abuse and neglect and matched controls (n = 833) were first interviewed as young adults (mean age = 29 years) from 1989 to 1995 and again in middle adulthood from 2000 to 2002 (mean age = 40 years) and 2003 to 2005 (mean age = 41 years). In middle adulthood, individuals with histories of childhood abuse and neglect were more likely to live in neighborhoods with more disorder and disadvantage and less social cohesion and advantage compared to controls and to engage in illicit drug use during the past year. Path analyses showed an indirect effect on illicit drug use via neighborhood disorder among maltreated children, even after accounting for drug abuse symptoms in young adulthood, although this was sex specific and race specific, affecting women and Whites. Overall, child abuse and neglect places children on a negative trajectory that dynamically influences negative outcomes at multiple levels into middle adulthood.