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Lowenstein M, Popova E, Jalloh A, Mazzella S, Botcheos D, Bertocchi J, Westfahl S, Garcia KP, Truchil R, Chertok J. The Mobile Overdose Response Program: A mobile, low-threshold opioid use disorder treatment model in Philadelphia. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 164:209429. [PMID: 38857828 DOI: 10.1016/j.josat.2024.209429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/04/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Low-threshold substance use treatment programs may help overcome barriers for marginalized individuals. The aims of this study were to 1) describe participant characteristics and treatment outcomes for a multi-site, Philadelphia-based mobile program providing street-based buprenorphine initiation, stabilization, and referral to ongoing care and 2) examine associations between patient characteristics and successful linkage. METHODS We conducted a retrospective cohort study of patients receiving buprenorphine through Prevention Point Philadelphia's mobile overdose response program from 9/2020-12/2021. We abstracted electronic medical record data, including patient characteristics, mobile program treatment, and care linkage. We used descriptive statistics to characterize the sample and assessed the association between patient characteristics and successful care linkage using multi-variable logistic regression. RESULTS Two hundred thirty-seven patients initiated buprenorphine in the program across six sites. Mean age was 46. Participants were majority men (67 %); 59 % identified as Black, 33 % identified as White, and 15 % reported Hispanic ethnicity. Most were publicly insured (74 %) and 30 % were unstably housed. Basedline engagement in primary care (32 %), psychiatric treatment (5 %), and counseling (2 %) were low. Most participants reported heroin or fentanyl use at intake (87 %), with high rates of IV drug use (37 %)., and co-occurring substance use and prior buprenorphine treatment experience were common.. 86 % completed ≥1 mobile follow-up visit, and 69 % completed ≥4 mobile program visits. 51 % of patients attended at least one visit at an outside site, and 30 % had ≥2 visits for buprenorphine prescriptions at an outside site. 35 % of the referrals were internal, meaning they went to University-based practices staffed by the mobile unit physicians. In a multivariable logistic regression model, internal referral was associated with significantly increased odds of effective care linkage (aOR 2.47, 95 % CI 1.20-5.09). CONCLUSIONS Targeted community outreach with low-threshold substance use care facilitated treatment access among marginalized individuals. Participants showed high levels of engagement with the mobile program, but rates of outside care linkage, while comparable to retention in other low-threshold models, were lower. The only predictor of effective care linkage was referral to brick-and-mortar clinics staffed by mobile unit physicians. These findings support the importance of outreach beyond traditional health care settings to engage high-risk patients with OUD.
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Affiliation(s)
- Margaret Lowenstein
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Ellena Popova
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Aminata Jalloh
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | - Rachael Truchil
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Judy Chertok
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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O'Shaughnessy BR, Mayock P, Kakar A. The recovery experiences of homeless service users with substance use disorder: A systematic review and qualitative meta-synthesis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 130:104528. [PMID: 39053034 DOI: 10.1016/j.drugpo.2024.104528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND The relationship between homelessness and substance use disorder (SUD) is layered and complex. Adults pursuing recovery while dealing with homelessness and SUD face many challenges. Little research has inspected qualitative first-person accounts of recovery in the context of homelessness and SUD, and few studies have employed conceptualisations of recovery beyond abstinence. In this systematic review study, we examine the qualitative literature on the recovery experiences of adult homeless service users with SUD. METHODS 2,042 records were identified via database and secondary searching strategy. After title and abstract and full text screening, 15 eligible studies remained. Critical Appraisal Skills Programme quality appraisal criteria was used to assess potential bias in the studies. Meta-ethnography was employed to synthesise extracted data. RESULTS Four themes were generated from the extracted data: Two sides of the Service Coin; Navigating Relationships; Recovery Practices and Personal Attributes; and Housing as Foundational for Recovery. CONCLUSION Unconditional housing, a broad array of supports, opportunities to contribute to society, and family reunification supports all facilitate the development of recovery for adults with SUD experiencing homelessness. Implications for policy are discussed.
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Affiliation(s)
- Branagh R O'Shaughnessy
- School of Social Work and Social Policy, Trinity College Dublin, College Green, Dublin 2, Ireland.
| | - Paula Mayock
- School of Social Work and Social Policy, Trinity College Dublin, College Green, Dublin 2, Ireland
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Israel BS, Belcher AM, Ford JD. A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders. J Dual Diagn 2024; 20:52-85. [PMID: 38165922 DOI: 10.1080/15504263.2023.2295416] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.
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Affiliation(s)
- Benjamin S Israel
- Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Annabelle M Belcher
- Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julian D Ford
- Department of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut, USA
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4
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Shearer RD, Howell BA, Khatri UG, Winkelman TN. Treatment setting among individuals with opioid use and criminal legal involvement, housing instability, or Medicaid insurance, 2015-2021. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 8:100179. [PMID: 37502021 PMCID: PMC10368753 DOI: 10.1016/j.dadr.2023.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 07/29/2023]
Abstract
Background Individuals with criminal legal involvement (CLI), housing instability, or Medicaid insurance may experience barriers accessing substance use treatment in certain settings. Previous research has found individuals in these groups are less likely to receive medications for opioid use disorder (MOUD), but the role treatment setting may play in low rates of MOUD is unclear. Methods We conducted a cross-sectional study using nationally representative survey data from 2015 to 2021. We estimated the proportion of individuals who had CLI, housing instability, or Medicaid insurance who received substance use treatment in a variety of settings. We used multivariable logistic regressions to estimate the associations between group and the receipt of MOUD across treatment settings. Results Individuals with CLI, housing instability, or Medicaid insurance were more likely to receive substance use treatment in hospitals, rehabilitation, and mental health facilities compared with individuals not in these groups. However, all groups accessed substance use treatment in doctors' offices at similar rates. Treatment at a doctor's office was associated with the highest likelihood of receiving MOUD (aOR 4.73 [95% CI: 2.2.15-10.43]). Across multiple treatment settings, Individuals with CLI or housing instability were less likely to receive MOUD. Conclusions Individuals with CLI, housing instability, or Medicaid insurance are more likely to access substance use treatment at locations associated with lower rates of MOUD use. MOUD access across treatment settings is needed to improve engagement and retention in treatment for patients experiencing structural disadvantage or who have low incomes.
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Affiliation(s)
- Riley D. Shearer
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN 55455, United States
| | - Benjamin A. Howell
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, United States
- SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT, United States
| | - Utsha G. Khatri
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Tyler N.A. Winkelman
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
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5
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Swartz N, Odayappan S, Chatterjee A, Cutler D. Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 152:209059. [PMID: 37207834 DOI: 10.1016/j.josat.2023.209059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/22/2023] [Accepted: 05/01/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION People experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals. METHODS The Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid. RESULTS Medicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, -18.6 to -5.07) percentage points less likely to have MOUD-inclusive treatment plans. CONCLUSIONS Medicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.
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Affiliation(s)
- Natalie Swartz
- Harvard College, 1 Harvard Yard, Cambridge, MA 02138, USA
| | | | - Avik Chatterjee
- Boston Health Care for the Homeless Program, 780 Albany St, Boston, MA 02118, USA; Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - David Cutler
- Department of Economics, Harvard University, 1805 Cambridge Street, Cambridge, MA 02138, USA
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Justen M, Scodes J, Pavlicova M, Choo TH, Gopaldas M, Haeny A, Opara O, Rhee TG, Rotrosen J, Nunes EV, Hawk K, Edelman EJ. Homelessness and Treatment Outcomes Among Black Adults With Opioid Use Disorder: A Secondary Analysis of X:BOT. J Addict Med 2023; 17:463-467. [PMID: 37579110 PMCID: PMC10323031 DOI: 10.1097/adm.0000000000001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to identify the sociodemographic and clinical characteristics associated with homelessnesss, and explore the relationship between homelessnesss and treatment outcomes among Black individuals. METHODS This is a secondary analysis of the subgroup of Black participants (n = 73) enrolled in "X:BOT," a 24-week multisite randomized clinical trial comparing the effectiveness of extended-release naltrexone versus sublingual buprenorphine-naloxone (n = 570). Outcomes included medication initiation, return to extramedical use of opioids assessed by both self-report and urine toxicology, and engagement in medications for opioid use disorder (MOUD) treatment at 28 weeks postrandomization. Descriptive statistics were performed. RESULTS Black participants were mostly unmarried and male, and about a third were aged 21-30 years. Among people experiencing homelessnesss, more were uninsured (45.5% [10/22] vs 19.6% [10/51]), unemployed (77.3% [17/22] vs 64.7% [33/51]), and reported alcohol (40.9% [9/22] vs 23.5% [12/51]) and sedative use (54.5% [12/22] vs 17.6% [9/51]) within the previous 30 days. Compared with housed Black individuals, a slightly higher proportion of Black individuals experiencing homelessnesss successfully initiated study medication (81.1% [18/22] vs 72.6% [37/51]); similar proportions returned to opioid use during the trial (68.2% [15/22] vs 68.6% [35/51]) and were engaged in MOUD at 28 weeks after trial entry (72.2% [13/18] vs 69.7% [23/33]) among participants located for follow-up. CONCLUSIONS These descriptive results among Black patients participating in a trial of MOUD suggest that efficacious MOUD is possible despite homelessnesss with additional clinical supports such as those provided by a clinical trial.
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Affiliation(s)
| | - Jennifer Scodes
- Department of Biostatistics, Brown University, Providence, RI, 02912, USA
- New York Psychiatric Institute, New York, NY, 10032, USA
| | - Martina Pavlicova
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Tse-Hwei Choo
- Division of Mental Health Data Science, New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Manesh Gopaldas
- New York State Psychiatric Institute, New York, NY, 10032, USA
- Columbia Irving Medical Center, New York, NY, 10032, USA
| | - Angela Haeny
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510
| | - Onumara Opara
- New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - John Rotrosen
- NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Edward V. Nunes
- New York State Psychiatric Institute, New York, NY, 10032, USA
- Columbia Irving Medical Center, New York, NY, 10032, USA
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
- Yale School of Public Health, New Haven, CT, 06510, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, 06510
| | - E. Jennifer Edelman
- Yale School of Public Health, New Haven, CT, 06510, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, 06510
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510
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7
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Jones AA, Strong-Jones S, Apsley HB. The role of polysubstance use on criminal justice involvement in the United States. Curr Opin Psychiatry 2023; 36:290-300. [PMID: 37191661 PMCID: PMC10280570 DOI: 10.1097/yco.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE OF REVIEW Polysubstance use, broadly defined as using more than one type of substance, disproportionately impacts those involved in the criminal justice system (CJS). This review synthesizes recent findings on polysubstance use among those involved in the CJS and highlights areas of particular concern and interventions. RECENT FINDINGS We use 18 recent articles to identify the prevalence and types of criminal justice involvement and correlates of polysubstance use and criminal justice involvement. We highlight latent patterns of polysubstance use among various criminal justice populations (adults, pregnant women, and youth) and differential associations with adverse substance use and criminal justice outcomes. Lastly, we discuss substance use treatment in the justice system, the role of polysubstance use in treatment access and outcomes, and substance use-related services for previously incarcerated individuals reentering society. SUMMARY Current research provides further evidence of the syndemic nature of polysubstance use, criminal justice involvement, and adverse outcomes, which are complicated by significant barriers to accessing evidence-based treatment in justice settings. Yet, current research is limited due to methodological inconsistency and limited focus on the social determinants of health, racial/ethnic disparities, and interventions to increase treatment and reentry services.
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Affiliation(s)
- Abenaa A Jones
- Department of Human Development and Family Studies, Pennsylvania State University
- Consortium on Substance Use and Addiction, Pennsylvania State University
| | - Sienna Strong-Jones
- Department of Human Development and Family Studies, Pennsylvania State University
| | - Hannah B Apsley
- Department of Human Development and Family Studies, Pennsylvania State University
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CERDÁ MAGDALENA, KRAWCZYK NOA, KEYES KATHERINE. The Future of the United States Overdose Crisis: Challenges and Opportunities. Milbank Q 2023; 101:478-506. [PMID: 36811204 PMCID: PMC10126987 DOI: 10.1111/1468-0009.12602] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.
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Affiliation(s)
- MAGDALENA CERDÁ
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
| | - NOA KRAWCZYK
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
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Gaeta Gazzola M, Carmichael ID, Christian NJ, Zheng X, Madden LM, Barry DT. A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States. Subst Abus 2023; 44:62-72. [PMID: 37226909 DOI: 10.1177/08897077231167291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement. METHODS Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates. RESULTS There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates. CONCLUSIONS Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.
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Affiliation(s)
- Marina Gaeta Gazzola
- APT Foundation, Inc., New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Emergency Medicine, NYU Langone Health/NYC Health and Hospitals Bellevue Hospital Center, New York, NY, USA
| | - Iain D Carmichael
- Department of Statistics, University of California at Berkeley, Berkeley, CA, USA
- Department of Pathology and Laboratory Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | | | - Xiaoying Zheng
- APT Foundation, Inc., New Haven, CT, USA
- New York University School of Medicine, New York, NY, USA
| | - Lynn M Madden
- APT Foundation, Inc., New Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Declan T Barry
- APT Foundation, Inc., New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
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10
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Arnos D, Acevedo A. Homelessness and Gender: Differences in Characteristics and Comorbidity of Substance Use Disorders at Admission to Services. Subst Use Misuse 2023; 58:27-35. [PMID: 36519365 DOI: 10.1080/10826084.2022.2136491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Substance use disorders and homelessness are two closely related behavioral health issues. This study examines associations between homelessness and severity of substance use disorder (SUD) characteristics (inclusive of alcohol and other legal and illegal drugs) and presence of mental health comorbidity among individuals entering treatment for SUD. We also examine differences in SUD and mental health comorbidity by gender within a sample of clients experiencing homelessness upon admission to treatment. Methods: Using the 2017 Treatment Episodes Data Set, we used logistic regression models to examine the association between homelessness and indicators of severity (e.g., frequency of use, route of transmission) and the presence of mental health conditions, and to examine the association between gender and these dependent variables among only individuals experiencing homelessness at treatment admission. Results: After controlling for covariates, homelessness is significantly associated with increased odds of cocaine and methamphetamine use compared to all other substances, higher frequency of use, younger age of first use, use of more substances, injection drug use, and co-occurring mental health conditions. Female gender is inversely associated with younger age at first use and highly associated with co-occurring mental health conditions among those experiencing homelessness at admission to treatment. Conclusions: Individuals experiencing homelessness enter substance use services with different characteristics of substance use disorders, different patterns of use, and with higher rates of mental health comorbidity. Within homeless admissions, women have significant differences in substance use and higher likelihood of mental health comorbidity than men. Future research should focus on the specific treatment needs of individuals experiencing homelessness, and how the combination of homelessness and gender affects barriers and challenges to treatment.
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Affiliation(s)
- Diane Arnos
- School of Public Health, University of California, Berkeley, California, USA
| | - Andrea Acevedo
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
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11
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Saloner B, Li W, Bandara SN, McGinty EE, Barry CL. Trends In The Use Of Treatment For Substance Use Disorders, 2010-19. Health Aff (Millwood) 2022; 41:696-702. [PMID: 35500189 PMCID: PMC10161241 DOI: 10.1377/hlthaff.2021.01767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment.
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Affiliation(s)
- Brendan Saloner
- Brendan Saloner , Johns Hopkins University, Baltimore, Maryland
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12
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Opioid Use Disorder and Racial/Ethnic Health Disparities: Prevention and Management. Curr Pain Headache Rep 2022; 26:129-137. [PMID: 35179723 DOI: 10.1007/s11916-022-01010-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize risks and disparities associated with the prevalence and treatment of opioid use disorder in the perioperative and long-term setting, as well as evidence-based treatment and prevention targeted toward specific vulnerable populations. RECENT FINDING There are significant demographic disparities in pain management and development and management of OUD in the chronic and surgical setting. While White patients traditionally receive more pain management, they are also at higher risk of developing OUD. Hispanic and Latin populations have the largest proportion of youth with OUD and often lack culturally appropriate translation services that allow for effective treatment. Native Americans have the second highest rate of OUD and often receive care in communities and healthcare settings that lack funding and resources to combat OUD. African Americans tend to suffer from the criminalization of OUD and are less able to seek treatment due to this, and furthermore, often lack community services that would benefit them. Additional vulnerable populations include homeless individuals that lack access to healthcare or health insurance. In addition, incarcerated individuals often lack access to naloxone and suffer from high rates of fatal overdose soon after being released to the community. People in rural settings lack needle-exchange programs and community-based interventions/support groups. Patients in the perioperative setting lack standard screening and pain management protocols. Interventions targeted toward each appropriate group can help decrease the rate of OUD and improve its treatment, and overarching interventions such as protocols, targeted funding, education and regulation can combat OUD for all populations.
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13
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Tofighi B, McNeely J, Yang J, Thomas A, Schatz D, Reed T, Krawczyk N. Outcomes of a NYC Public Hospital System Low-Threshold Tele-Buprenorphine Bridge Clinic at 1 Year. Subst Use Misuse 2022; 57:1337-1340. [PMID: 35481461 PMCID: PMC10107046 DOI: 10.1080/10826084.2022.2069269] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: This study evaluated clinical outcomes of a low barrier tele-buprenorphine bridge program for NYC residents with opioid use disorder (OUD) at 1 year during the coronavirus disease 2019 (COVID-19) pandemic. Methods and materials: This retrospective analysis of the NYC Health + Hospitals (NYC H + H) Virtual Buprenorphine Clinic registry assessed baseline demographic and clinical characteristics, rates of referrals to community treatment, and induction-related adverse events among city residents with OUD, from March 2020 to the end of March 2021. Results: The program enrolled 199 patients, of whom 62.3% were provided same-day visits (n = 124). Patients were enrolled in the program for a median of 14 days (range 0-130 days). Referrals sources included hospital and clinic staff (n = 83, 47.7%), word of mouth (n = 30, 17.2%), and correctional health or reentry services (n = 30, 17.2%). Induction-related adverse events were mostly limited to precipitated withdrawal symptoms (n = 21, 5%). Roughly half of patients were referred to community treatment (n = 109, 54.8%) and of those 51.4% (n = 56/109) completed at least one visit in community treatment. Discussion: Our experience indicates that a low threshold tele-buprenorphine bridge program in place of a safe and feasible approach to facilitating entry in community treatment for underserved people who use opioids in a large metropolitan area.
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Affiliation(s)
- Babak Tofighi
- Department of Population Health, New York University School of Medicine, New York, New York, USA.,Bellevue Hospital Center Division of General Internal Medicine, New York, New York, USA.,Center for Drug Use and HIV Research, New York, New York, USA
| | - Jennifer McNeely
- Department of Population Health, New York University School of Medicine, New York, New York, USA.,Bellevue Hospital Center Division of General Internal Medicine, New York, New York, USA.,Center for Drug Use and HIV Research, New York, New York, USA
| | - Jenny Yang
- Department of Population Health, New York University School of Medicine, New York, New York, USA.,Department of Psychiatry, Bellevue Hospital Center, New York, New York, USA
| | - Anil Thomas
- Department of Psychiatry, New York University School of Medicine, New York, New York, USA.,Department of Psychiatry, Bellevue Hospital Center, New York, New York, USA
| | - Daniel Schatz
- Department of Population Health, New York University School of Medicine, New York, New York, USA.,Bellevue Hospital Center Division of General Internal Medicine, New York, New York, USA.,NYC Health + Hospitals Office of Behavioral Health, New York, New York, USA
| | - Timothy Reed
- Department of Psychiatry, Bellevue Hospital Center, New York, New York, USA
| | - Noa Krawczyk
- Department of Population Health, New York University School of Medicine, New York, New York, USA.,Center for Drug Use and HIV Research, New York, New York, USA
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Padwa H, Bass B, Urada D. Homelessness and publicly funded substance use disorder treatment in California, 2016-2019: Analysis of treatment needs, level of care placement, and outcomes. J Subst Abuse Treat 2021; 137:108711. [PMID: 35012791 DOI: 10.1016/j.jsat.2021.108711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/04/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Both homelessness and substance use have increased in recent years. People experiencing homelessness (PEH) are at increased risk for health problems and early mortality, both of which can be exacerbated by substance use disorders (SUD). Specialty SUD treatment is likely needed to address substance use among PEH, and more than 232,000 PEH received treatment from U.S. publicly funded SUD programs in 2015. The objective of this paper is to develop a better understanding of the SUD services that PEH receive in publicly funded treatment programs by (1) describing the characteristics and needs of the PEH population served in publicly funded SUD treatment programs, compared to non-PEH populations; (2) determining if differences exist in treatment placement (level of care) for PEH and non-PEH; and (3) gauging how successful programs are in treating PEH compared to non-PEH. METHODS Observational study using a two-way fixed effect model to determine associations among homelessness, retention, and outcomes among Medicaid beneficiaries receiving SUD treatment in California from 2016 to 2019 (n = 638,953). The study team used ordinary least squares (OLS) regression to measure the degree to which homelessness was associated with baseline characteristics, SUD services received, and treatment outcomes. RESULTS PEH were significantly more likely than non-PEH to be having methamphetamine or heroin as their primary substance. PEH had greater frequency of primary substance use prior to entering treatment, greater ER and hospital utilization, more criminal justice involvement, and greater prevalence of mental health diagnoses and unemployment. PEH were 9.82% more likely than non-PEH to receive residential treatment and 7.11% less likely than non-PEH to receive treatment intensive outpatient modalities. Homelessness was associated with an 11.90% decrease in retention, and a 19.40% decrease in successful discharge status. These trends were consistent across outpatient, intensive outpatient, and residential modalities. CONCLUSIONS Developing SUD treatment capacity and housing supports can improve treatment outcomes for PEH. Potential strategies to improve SUD services for PEH include providing more contingency management, opioid pharmacotherapies, programming designed to treat individuals with co-occurring mental health disorders, and resources for housing options that can support PEH in their recovery.
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Affiliation(s)
- Howard Padwa
- University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA 90025, United States of America.
| | - Brittany Bass
- University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA 90025, United States of America
| | - Darren Urada
- University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA 90025, United States of America
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