To what extent are key services offered in treatment programs for special populations?

The availability of LGBT-specific mental health and substance abuse treatment in the United States

OBJECTIVE

To examine the availability and facility-level predictors of LGBT-specific mental health and substance abuse treatment in the United States.

DATA SOURCES/STUDY SETTING

2016 National Survey of Substance Abuse Treatment Services, 2016 National Mental Health Service Survey, and 2015-2016 Gallup Daily tracking survey.

STUDY DESIGN

Logistic regression models and average marginal effects were used to identify characteristics of facilities that offer LGBT-specific programs. Linear regression models were used to estimate the association between the state-level proportion of LGBT people and the proportion of facilities that offer LGBT-specific programs.

DATA COLLECTION/EXTRACTION METHODS

Secondary data analysis. Cases with missing values for any predictor were excluded.

PRINCIPLE FINDINGS

12.6 percent of mental health and 17.6 percent of substance abuse facilities reported LGBT-specific programs. Several facility characteristics were statistically associated with the likelihood of mental health and substance abuse facilities providing LGBT-specific programs, including offering outpatient or residential treatment, private ownership, religious affiliation, and payment type. The proportion of LGBT adults living within each state was statistically associated with state-level density of LGBT-specific mental health programs, but not substance abuse programs.

CONCLUSIONS

Findings suggest limited availability of culturally competent mental health and substance abuse treatment, despite well-documented need.

An Exploration of Mothers' Successful Completion of Family-Centered Residential Substance Use Treatment

Behavioral health and substance use centers have started focusing efforts on creating, adopting, and implementing evidence-based practices and programs that effectively address the needs of women and, particularly, mothers entering treatment with children. However, women with substance use disorders (SUDs) remain an underserved and understudied population; even less studied are the complexities and unique SUD treatment needs of women who have children. Family therapists' systemic training is a valued approach in conceptualizing and implementing treatment for mothers with SUDs and their families. This study explored the construct of mothering children during family-centered substance use treatment using a transcendental phenomenological approach. Analysis revealed themes related to motherhood, parenting, and support for mothers and children. Two themes emerged from the data: (a) grappling with motherhood and addiction leading to the decision for treatment and (b) specific aspects of the treatment program conducive to motherhood. Results indicated the positive impact of mothers' experiences in family-centered substance use treatment, aligning with previous literature that suggests mothers are more engaged in treatment when their children remain in their care. The insights gleaned from the participants in this study provide suggestions for further improving programming that supports mothers and their children during the recovery process. Treatment considerations are offered for family therapists working with mothers with SUDs and their families.

Double-edged sword of federalism: variation in essential health benefits for mental health and substance use disorder coverage in states

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Special Services for Women in Substance Use Disorders Treatment: How Does the Department of Veterans Affairs Compare with Other Providers?

BACKGROUND

Gender is an important consideration in the treatment of substance use disorders (SUD). Although the number of women seeking care through the Department of Veterans Affairs (VA) has increased dramatically, little is known about the capacity of the VA to meet the needs of women with SUD. We examined the prevalence of programs and key services for women in VA facilities in a survey of 14,311 SUD treatment facilities.

METHODS

Using data from the 2012 National Survey of Substance Abuse Treatment Services, we calculated the percent of VA facilities offering special programs or groups exclusively for women, compared with facilities under other types of ownership. For each ownership type, we also calculated the mean number of ancillary services offered that are critical for many women in SUD treatment, including child care, domestic violence counseling, and transportation assistance. Multivariable models were used to adjust for differences in other facility characteristics.

FINDINGS

Approximately 31% of facilities had special programs exclusively for women. The VA had the lowest prevalence of programs for women, at 19.1%; however, the VA offered an average of 5 key services for women, which was significantly higher than the averages for other federal (n = 2), local (n = 4), and private for-profit (n = 2) facilities. Results were generally robust to multivariable adjustments.

CONCLUSIONS

The VA should consider developing more SUD programs and groups exclusively for women, while maintaining ancillary services at their relatively abundant level. Gender-specific programs and groups could serve as points of referral to ancillary services for women veterans.

National Trends in Adolescent Substance Use Disorders and Treatment Availability: 2003-2010

This study examines trends in adolescent substance use disorders (SUDs) and treatment utilization in the US using data from the National Household Survey on Drug Use and Health (NSDUH) and data from the National Survey of Substance Abuse Treatment Services (N-SSATS). Results indicate an overall decrease in the percent of adolescents meeting past year criteria for an alcohol or illicit drug disorder between 2003 and 2010, but the percent of adolescents meeting criteria who had not received any treatment in the past year was substantial and has remained stable since 2003. In 2010, less than 30% of facilities participating in the N-SSATS survey indicated that they offered special programming for adolescents, reflecting an overall decrease since 2003.

Developing Community Reinforcement and Family Training (CRAFT) for Parents of Treatment-Resistant Adolescents

We describe a project focused on training parents to facilitate their treatment-resistant adolescent's treatment entry and to manage their child after entry into community-based treatment. Controlled studies show that Community Reinforcement and Family Training (CRAFT) is a unilateral treatment that fosters treatment entry of adults; however, there are no controlled trials for parents with a substance-abusing child. We examined the behavioral parent training literature to guide us in tailoring CRAFT for parents of adolescents. We discuss adaptations to CRAFT, outcomes and experiences gained from a brief pilot of the revised CRAFT program, and the future directions of this work.

Organizational Predictors and Use of Evidence-Based Practices in Adolescent Substance Abuse Treatment

BACKGROUND

Adolescent substance abuse remains a significant problem in the United States, yet treatment centers do not always admit adolescent clients. In this paper, we first determine the extent to which treatment is available for adolescents in general and whether or not adolescent-specific (segregated) tracks are offered. Second, we examine the organizational characteristics associated with adolescent treatment. Third, we illuminate how the adolescent caseload in a treatment center is related to offering evidence-based practices (EBPs).

METHODS

Drawing upon a nationally representative sample of US treatment programs, we use logistic regression to assess how organizational characteristics are associated with the provision of adolescent treatment. Using ordinal logistic regression, we analyze how the treatment center's adolescent caseload and organizational characteristics affect the extent to which a treatment center offers medication-assisted treatment (MAT) and psychosocial treatment.

RESULTS

Half (49.5%) of treatment programs admitted adolescents, and 41.8% offered an adolescent-specific track. Findings from the logistic regression suggested several organizational characteristics that were significantly associated with treating adolescents and/or having an adolescent-only track. Our findings from the ordinal models indicated a negative relationship between the percent of adolescents in a treatment center and the extent of MAT, and a positive relationship between the percent of adolescent clients and the extent of psychosocial treatment offered.

CONCLUSIONS

This paper highlights organizational barriers to treatment entry for adolescents, who remain a small proportion of clients in treatment centers. When treatment centers serve adolescents, however, those adolescents are likely to receive care in adolescent-only tracks and/or services and in programs that offer several psychosocial EBPs. Finally, adolescents are less likely to receive treatment in centers that offer a variety of MAT.

Integrated Substance Abuse and Child Welfare Services for Women: A Progress Review

A review of empirical literature reveals improvements in service utilization and outcomes for women when substance abuse and child welfare services are integrated. The increased use of substances by women involved in the child welfare system has resulted in a call for integrated, coordinated, evidence-based practices. Since the late 1990s, specific system- and service-level strategies have been developed to coordinate and integrate the provision of substance abuse and child welfare services such that women are remaining in treatment longer and are more likely to reduce substance use and be reunited with their children. The strategies reviewed provide useful guidelines for developing components of effective, evidence-based programs for substance-involved women in the child welfare system.

Workforce professionalism in drug treatment services: impact of California's Proposition 36

This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.

Gender differences in client-provider relationship as active ingredient in substance abuse treatment

The client-provider relationship is increasingly evaluated as an active ingredient in the delivery of substance abuse treatment services. This study examines gender differences in client-provider relationship as an important treatment ingredient affecting retention in treatment and reduced post-treatment substance use. The study uses data collected for the National Treatment Improvement Evaluation Study (NTIES), a prospective, cohort study of U.S. substance abuse treatment programs and their clients. Data on individual characteristics were collected at the pre-treatment interview; on client-provider relationship and services received at treatment exit; and on post-treatment drug use at 12 months post-treatment. The analytic sample consists of 3027 clients from 59 service delivery units (1922 men and 1105 women). Structural equation modeling (SEM) was used to assess the structural relations and causal connections between relationship and service variables and treatment outcome variables. Results indicate that a positive client-provider relationship is related directly to longer duration and reduced post-treatment drug use for the total sample and for men analyzed separately. For women, a positive client-provider relationship was related directly to treatment duration and only indirectly to reduced post-treatment drug use. The findings point to the significance of including client-provider relationship in service delivery models--both as a therapeutic element as well as an element facilitative of matching services to specific client needs.

Developing an integrated treatment for substance use and depression using cognitive-behavioral therapy

Providing a unified treatment approach to meet the substance abuse and mental health needs of clients is the preferred model for addressing co-occurring disorders. We developed a group-based cognitive-behavioral (CBT) integrated treatment for depression and substance use disorders (SUD) that could be delivered by counselors in SUD treatment settings and evaluated its feasibility and acceptability. We conducted an in-depth case study examining one implementation of the treatment using 15 focus groups with clients (n = 7) and semistructured interviews with counselors (n = 2) and administrators (n = 3). Using CBT as a treatment approach to integrate the treatment was widely accepted by clients, counselors, and administrators. Clients stated the treatment was applicable to multiple aspects of their lives and allowed them to recognize their clinical improvements over time. Counselors and administrators discussed challenges for long-term feasibility. Key decisions used to develop the treatment and recommendations for implementing integrated care in SUD settings are discussed.

Service engagement with high-risk men who have sex with men: challenges and implications for social work practice

This article reviews social work challenges in treatment engagement of men who have sex with men (MSM) and details issues co-morbidity creates for reaching HIV-positive MSM engaged in substance abuse. The literature reviewed within the article identifies HIV and substance use risk factors influencing out of care dynamics and examines relevant research identifying contextual and cultural factors central to achieving cultural competence. The article examines aspects of cultural sensitivity and competence in service development and engagement and identifies service qualities and characteristics social workers can incorporate into practice and programs to increase the likelihood of successful engagement and treatment adherence.

Adolescent-only substance abuse treatment: availability and adoption of components of quality

There are few studies of the availability and quality of adolescent-only treatment programs. Drawing upon existing samples of publicly and privately funded treatment programs, this research considers whether organizational characteristics are associated with the availability of adolescent-only programming and measures components of quality within these programs. Significant organizational correlates of adolescent-only services included organizational size, location within a hospital setting, center accreditation, adherence to a 12-step treatment model, and reliance on public sources of funding. In-depth interviews were then conducted with 154 managers of adolescent-only treatment programs regarding levels of care offered and service quality. The most prevalent levels of care were standard outpatient and intensive outpatient. Analysis of nine domains of treatment quality revealed a medium level of quality. Treatment quality was significantly greater in programs offering more intensive levels of care. These results are largely consistent with other recent research and suggest a need for continued quality improvement efforts in this treatment sector.

Do drug treatment services predict reunification outcomes of mothers and their children in child welfare?

The effect of mothers' participation in substance abuse treatment on reunification with their children who are in out-of-home care is an important policy issue. This article examines the predictors of child reunification among mothers who participated in a statewide treatment outcome study. Data were integrated from multiple sources to determine the contributions of characteristics of mothers (n = 1,115), their children (n = 2,299), and treatment programs (n = 43) on reunification outcomes. Hierarchical linear modeling was used to determine the fixed and random effects of mother, child, and program characteristics. Mothers with more employment and psychiatric problems were less likely to be reunified with their children; completion of 90 or more days in treatment approximately doubled their likelihood of reunification. Mothers who were treated in programs providing a "high" level of family-related or education/employment services were approximately twice as likely to reunify with their children as those who were treated in programs with "low" levels of these services.

Characteristics of facilities with specialized programming for drinking drivers and for other criminal justice involved clients: analysis of a national database

Background

Offering specialized programming at substance abuse treatment facilities can help diversify clientele and funding sources, potentially enhancing the facilities' ability to survive and/or expand. Past research has shown that facilities only offering specialized programming for driving under the influence/driving while intoxicated offenders (DUI) are predominately private-for-profit owned. As criminal justice populations, both DUI and other criminal justice offenders, comprise a large proportion of those in community-based substance abuse treatment knowing facilities' characteristics would be important for administrators and policymakers to consider when updating programming, training staff or expanding capacity to ensure efficient use of scarce resources. However, while such characteristics are known for DUI programs, they are not known for facilities offering specialized programming for other criminal justice offenders.

Methods

Analysis of the 2004 US National Survey of Substance Abuse Treatment Facilities.

Results

Almost half the facilities (48.2%) offered either DUI or other criminal justice specialized programming. These facilities were divided between those offering DUI specialized programming (17.7%), other criminal justice specialized programming (16.6%) and both types of programming (13.9%). Certain characteristics were independently associated with offering DUI specialized programming (private ownership, rural location, for profit status) or other criminal justice specialized programming (receiving public funds, urban location, region of country).

Conclusion

Offering specialized programming for DUI or other criminal justice offenders was common and associated with distinct characteristics. These observed associations may reflect the positioning of the facility to increase visibility, or diversify clientele and possibly funding streams or the decision of policymakers. As the criminal justice populations show no sign of decreasing and resources are scarce, the efficient use of resources demands policymakers recognize the prevalence of these specialized programming, join forces to examine them for efficacy, and explicitly incorporate these characteristics into strategies for workforce training and plans for treatment expansion.

Organizational characteristics of drug abuse treatment programs for offenders

This article examines the association between the organizational characteristics of drug abuse treatment programs for offenders and the provision of wraparound services and three types of treatment orientations. Data are from the National Criminal Justice Treatment Practices Survey, which was conducted with program directors (N = 217). A greater number of wraparound services provided were associated with inpatient treatment, specialized treatment facilities, community setting (vs. correctional), services provided for more types of client populations, college-educated staff, and planned treatment for > 180 days. Therapeutic community orientation was associated with prison-based treatment and specialized treatment facilities. Cognitive-behavioral therapy orientation was associated with higher perceived importance of community treatment, more perceived staff influence on treatment, and treatment for 91-180 days. The 12-step orientation was most strongly associated with having staff specialized in substance abuse. Study findings have implications for developing effective reentry programs for offenders that bridge correctional and community treatment.

Do specialized services exist for LGBT individuals seeking treatment for substance misuse? A study of available treatment programs

Substance abuse research has demonstrated that client sexual orientation influences treatment outcomes. Consequently, many substance user treatment programs offer services for lesbian, gay, bisexual, and transgender (LGBT) individuals. In a recent search of SAMHSA treatment listings, 11.8% (N=911) of substance user treatment programs (including residential, outpatient, and partial hospitalization) in the United States and Puerto Rico indicated that they offer specialized services for LGBT clients. However, a telephone survey we conducted in 2003-2004 revealed that 70.8% of these "LGBT" programs were no different from services offered to the general population, and only 7.4% could identify a service specifically tailored to the needs of LGBT clients. Implications for LGBT individuals seeking services are discussed, the study's limitations are noted, and future research directions are identified.

Characteristics of U.S. substance abuse treatment facilities adopting buprenorphine in its initial stage of availability

This study examined the adoption of buprenorphine for the treatment of opiate dependence among U.S. substance abuse treatment facilities and their characteristics at the time of the initial availability of the medication. Data come from a 2003 national survey of all substance abuse treatment facilities in the U.S. Out of our sample of 13,060 facilities, 5.5% of facilities reported they offered buprenorphine. Not unexpectedly, the prevalence was higher in certified opioid treatment programs (11.3%) compared to other facilities (4.6%). For opioid treatment programs, offering Naltrexone (OR=8.34, 95% CI=5.53, 12.58) and offering medically supervised withdrawal (OR=2.76, 95% CI=1.38, 5.52) were independent and robust predictors of offering buprenorphine. These same variables were independent predictors for the non-opioid treatment programs as well (Naltrexone, OR=14.32, 95% CI=7.85, 26.10; and medically supervised withdrawal services, OR=4.42, 95% CI=3.01, 6.49). Our results suggest that the adoption of buprenorphine soon after the Food and Drug Administration approved its use for treatment of opioid dependence and the shipping of the medication commenced was associated with facilities already offering pharmacotherapies such as Naltrexone and medically assisted withdrawal. These findings provide baseline data to track the adoption of buprenorphine by substance abuse treatment programs in future years.

Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment

Previous research has suggested that lesbian, gay, bisexual, and transgender (LGBT) individuals enter treatment for substance abuse with more severe problems than heterosexual individuals. However, methodological difficulties, particularly the difficulty of obtaining a representative sample, have limited the ability to draw conclusions about LGBT individuals who receive services for substance abuse. This study took advantage of a unique opportunity to examine a representative sample of openly LGBT clients receiving publicly funded substance abuse treatment by using data gathered by treatment providers in Washington State. Baseline differences between openly LGBT and heterosexual clients were compared in a variety of domains. Results demonstrated that openly LGBT clients enter treatment with more severe substance abuse problems, greater psychopathology, and greater medical service utilization when compared with heterosexual clients. When the analyses were stratified based on sex, different patterns of substance use and associated psychosocial characteristics emerged for the LGBT clients. Implications for provision of appropriate services and recommendations to treatment agencies are discussed in this article.

Availability of Services for Women in Outpatient Substance Abuse Treatment: 1995–2000

Women entering substance abuse treatment have more severe substance abuse problems and more medical and psychiatric comorbidities than men. Research shows that specialized women's services are associated with better retention and outcomes but relatively little is known about their availability nationwide. This study examined the adoption and implementation of reproductive and female-sensitive social services in a national sample of outpatient substance abuse treatment (OSAT) organizations in 1995 (N = 617) and 2000 (N = 571) by several organizational factors. Overall, reproductive and social services for women have not been widely adopted, although some services did increase over the study period, particularly social services. There was no evidence of large-scale decreases in service availability over the study period, although child care did decline. Nonprofit and public ownership (relative to for-profit) were associated with greater service provision. Managed care units had greater service adoption compared to nonmanaged care units, and this increased over time. Public units and hospital-affiliated units had greater service implementation than other units. However, OSAT units did not always implement the services they adopted, suggesting access to some services may be restricted.

Mothers in substance abuse treatment: differences in characteristics based on involvement with child welfare services

PROBLEM

Greater awareness of the role of parental substance abuse in child maltreatment makes it imperative that the substance abuse treatment and child welfare systems coordinate services for these parents. Yet little is known about the characteristics of child-welfare involved parents (primarily mothers) who enter into substance abuse treatment. This paper compares the characteristics of mothers in substance abuse treatment who were and were not involved with child welfare services, and discusses the treatment implications of these differences.

METHOD

Data were obtained from a statewide treatment outcome monitoring project in California. Clients were assessed at treatment admission using the Addiction Severity Index. Bivariate analyses and multivariate logistic regression were conducted comparing mothers who were (N=1,939) and were not (N=2,217) involved with child welfare.

RESULTS

Mothers who were involved with child welfare were younger, had more children, and had more economic problems. They were more likely to be referred by the criminal justice system or other service providers, to have a history of physical abuse, and to be treated in outpatient programs. They had lower levels of alcohol severity, but did not differ with regard to psychiatric severity or criminal involvement. Primary users of methamphetamine were disproportionately represented among this group and had a distinct profile from primary alcohol- and opiate-users.

CONCLUSION

Study findings suggest that mothers involved with child welfare enter substance abuse treatment through different avenues and present a clinical profile of treatment needs related to exposure to physical abuse, economic instability, and criminal justice involvement.

Does the impact of managed care on substance abuse treatment services vary by provider profit status?

OBJECTIVE

To extend our previous research by determining whether, and how, the impact of managed care (MC) on substance abuse treatment (SAT) services differs by facility ownership.

DATA SOURCES

The 2000 National Survey of Substance Abuse Treatment Services, which is designed to collect data on service offerings and other characteristics of SAT facilities in the U.S. These data are merged with data from the 2002 Area Resource File, a county-specific database containing information on population and MC activity. We use data on 10,513 facilities, virtually a census of all SAT facilities.

STUDY DESIGN

For each facility ownership type (for-profit [FP], not-for-profit [NFP], public), we estimate the impact of MC on the number and types of SAT services offered. We use instrumental variables techniques that account for possible endogeneity between facilities' involvement in MC and service offerings.

PRINCIPAL FINDINGS

We find that the impact of MC on SAT service offerings differs in magnitude and direction by facility ownership. On average, MC causes FPs to offer approximately four additional services, causes publics to offer approximately four fewer services, and has no impact on the number of services offered by NFPs. The differential impact of MC on FPs and publics appears to be concentrated in therapy/counseling, medical testing, and transitional services.

CONCLUSION

Our findings raise policy concerns that MC may reduce the quality of care provided by public SAT facilities by limiting the range of services offered. On the other hand, we find that FP clinics increase their range of services. One explanation is that MC results in standardization of service offerings across facilities of different ownership type. Further research is needed to better understand both the specific mechanisms of MC on SAT and the net impact on society.

Substance use and social identity in the lesbian community

Although the study results report discrepancies in the rates of substance abuse in the lesbian community, the general consensus in the field of gay and lesbian studies is that these individuals, as a whole, have a higher rate of substance use. For this study, data were collected via the Internet on the use of drugs and alcohol, level of self-esteem, and degree of social identity in the lesbian community. A correlation analysis was used to determine if negative social identity within the lesbian community leads to low self-esteem that is reflected in higher rates of substance abuse. Though a positive relationship between social identity and self-esteem was determined, no significant correlation between negative social identity, low self-esteem, and substance use was determined. However, it is important to consider that respondents with higher levels of self-esteem reported more frequent use of specific drugs. That outcome in itself is an implication for further investigation.