Substance use disorders among older populations: What role do race and ethnicity play in treatment and completion?

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use

Substance use is one of the most common risk factors contributing to complications following total joint arthroplasty. Preoperative optimization programs can help patients modify or stop substance use. The purpose of this study was to provide recommendations and resources that will help nurse navigators standardize and improve preoperative optimization protocols regarding substance use. In a semistructured format, we asked nurse navigators how smoking, alcohol use, and opioid use were addressed. We conducted a literature review and combined findings with nurse navigator reports to create practice recommendations. We recommend consistently referring patients who smoke to smoking cessation programs; using validated screening tools to evaluate alcohol use and involving internists in caring for patients at risk for withdrawal; and involving pain specialists and local resources to assist patients who use opioids. There is a breadth of resources for managing substance use that nurse navigators can utilize to support stronger and more consistent preoperative optimization protocols.

The highs and the lows: Recreational marijuana laws and mental health treatment

Recreational marijuana laws (RMLs) continue to grow in popularity, but the effects on mental health treatment are unclear. This paper uses an event-study within a difference-in-differences framework to study the short-run impact of state RMLs on admissions into mental health treatment facilities. The results indicate that shortly after a state adopts an RML, they experience a decrease in the average number of mental health treatment admissions. The findings are driven by white, Black, and Medicaid-funded admissions and are consistent for both male and female admissions. The results are robust to alternative specifications and sensitivity analysis.

Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia

Introduction

There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality.

Methods

Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses.

Results

Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (β=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (β=0.01, p=0.002) or with mental health disorders (β= -0.12, p<0.001), despite higher fatal opioid overdoses.

Conclusions

There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act

This study uses a difference-in-differences design within an event-study framework to examine how state decisions to expand Medicaid following the passage of the Affordable Care Act (ACA) affected mental health treatment. The findings suggest that expansion states experienced increased admissions to mental health treatment facilities and Medicaid-reimbursed prescriptions for medications used to treat common forms of mental illness. The results also indicate an increase in admissions with trauma, anxiety, conduct, and depression disorders. There is also suggestive evidence of an increase in the number of mental health treatment facilities accepting Medicaid as a form of payment. Lastly, as with previous studies, I find weak evidence of a decrease in suicides in Medicaid expansion states. These findings highlight the vital role of the ACA in providing access to mental health treatment for low-income Americans.