Identifying substance abuse treatment gaps in substate areas

Key Considerations in Planning for Substance Use Treatment: Estimating Treatment Need and Demand

Objective:

Estimates of the extent of treatment need (defined by the presence of a diagnosis for which there is an effective treatment available) and treatment demand (defined as treatment seeking) are essential parts of effective treatment planning, service provision, and treatment funding. This article reviews the existing literature on approaches to estimating need and demand and the use of models to inform such estimation, and then considers the implications for health planners.

Method:

A thematic review of the literature was undertaken, with a focus on covering the key concepts and research methods that have been used to date.

Results:

Both need and demand are important estimates in planning for services but contain many difficulties in moving from the theory of measurement to the practicalities of establishing these figures. Furthermore, the simple quantum of need or demand is limited in its usefulness unless it is matched with consideration of different treatment types and their relative intensity, and/or explored as a function of geography and subpopulation. Modeling can assist with establishing more fine-tuned planning estimates, and is able to take into account both client severity and the various treatment types that might be available.

Conclusions:

Moving from relatively simplistic estimates of need and demand for treatment, this review has shown that although such estimation can inform national or subnational treatment planning, more sophisticated models are required for alcohol and other drug treatment planning. These can help health planners to determine the appropriate amount and mix of treatments for substance use disorders.

Objectif :

L’estimation de l’ampleur du besoin de traitement, défini par la présence d’un diagnostic pour lequel un traitement efficace est disponible, et la demande de traitement, définie par la recherche de traitement, sont des éléments essentiels à une planification efficace du traitement, à la prestation de service et à son financement. Cet article passe en revue la littérature existante sur les approches pour estimer le besoin et la demande ainsi que l’utilisation de modèles pour documenter une telle estimation, puis considère les implications pour les planificateurs des services de santé.

Méthode :

Une revue thématique de la littérature a été entreprise en mettant l’accent sur les concepts clés et les méthodes de recherche qui ont été utilisées à ce jour.

Résultats :

Les estimations des besoins et de la demande sont toutes deux importantes dans la planification des services, mais constituent des défis importants lors du passage de la théorie de la mesure aux aspects plus pratiques de production de ces estimations. Par ailleurs, la simple estimation d’un nombre lié au besoin ou à la demande est limitée, à moins qu’elle ne soit appariée avec différents types de traitement et leur intensité respective, ou explorée avec d’autres facteurs géographiques et de sous-population. La modélisation aide à produire des estimations de planification plus précises et permet de prendre en compte à la fois la sévérité des problèmes du client et les types de traitement qui pourraient être disponibles.

Conclusion:

En partant d’estimations relativement simplistes des besoins et de la demande de traitement, cette revue a montré que si ce genre d’estimation peut éclairer la planification des traitements à l’échelle nationale ou régionale, d’autres modèles plus sophistiqués sont nécessaires pour la planification des traitements des problèmes liés à l’usage d’alcool et des autres drogues. Ceux-ci peuvent aider les planificateurs des services de santé à déterminer la quantité et la combinaison appropriées de traitement pour les troubles liés à l’utilisation de substances.

Objetivo:

Las estimaciones de la magnitud de las necesidades de tratamiento, que se define por la presencia de un diagnóstico para el cual existe un tratamiento efectivo disponible, y la demanda de tratamiento, definida como la búsqueda de tratamiento, son parte esencial de la planificación de un tratamiento eficaz, la prestación de servicios y la financiación del tratamiento. Este artículo revisa la literatura existente sobre enfoques para estimar la necesidad y la demanda y el uso de modelos para informar a dicha estimación, y luego considera las implicaciones para los planificadores de salud.

Método:

Se realizó una revisión temática de la literatura, con un enfoque en cubrir los conceptos clave y los métodos de investigación que se han empleado hasta la fecha.

Resultados:

Tanto la necesidad como la demanda son estimaciones importantes en la planificación de los servicios, pero contienen muchas dificultades para pasar de la teoría de la medición a los aspectos prácticos de establecer estas cifras. Además, el simple quantum de necesidad o demanda es limitado en su utilidad a menos que se corresponda con la consideración de diferentes tipos de tratamiento y su intensidad relativa, y / o explorado como una función de la geografía y la subpoblación. El modelado puede ayudar a establecer estimaciones de planificación más precisas, y puede tener en cuenta tanto la gravedad del cliente como los diversos tipos de tratamiento que podrían estar disponibles.

Conclusiones:

Pasando de estimaciones relativamente simplistas de la necesidad y demanda de tratamiento, esta revisión ha demostrado que, si bien dicha estimación puede informar la planificación del tratamiento nacional o subnacional, se requieren modelos más sofisticados para la planificación del tratamiento del alcohol y otras drogas. Estos pueden ayudar a los planificadores de salud a determinar la cantidad apropiada y la combinación de tratamientos para los trastornos por uso de sustancias.

Measuring Unmet Demand for Alcohol and Other Drug Treatment: The Application of an Australian Population-Based Planning Model

Objective:

The estimation of demand for treatment is one of the important elements in planning for alcohol and other drug treatment services. This article reports on a demand-projection model used in Australia to estimate the extent of unmet treatment demand by drug type.

Method:

The model incorporated the prevalence of substance use disorders (by drug type and age), with the application of a severity distribution, which distributed the substance abuse disorders into three disability categories: mild, moderate, and severe. The application of treatment rates derived from expert judgments reflecting the proportion of people within disability categories who would be suitable for, likely to seek, and benefit from treatment. Sensitivity analyses incorporating variations to the severity distributions and treatment rates were applied, along with adjustment for polydrug use.

Results:

The estimate for treatment demand for Australia varied between a low of 411,740 people and a high of 755,557 people. The most sensitive parameter is the expected treatment-seeking rate. Given that approximately 200,000 to 230,000 people are currently in treatment, this represents a met demand of between 26.8% and 56.4%.

Conclusions:

There is insufficient alcohol and drug treatment available to meet the demand in Australia, despite Australia’s relatively high met demand, when compared with other countries.

Objectif :

L’estimation de la demande de traitement est l’un des éléments importants de la planification des services de traitement liés à l’usage d’alcool et d’autres drogues. Cet article porte sur un modèle de projection de la demande, utilisé en Australie pour estimer l’étendue de la demande de traitement non-satisfaite par type de substance consommée.

Méthode :

Le modèle intègre la prévalence des troubles de l’utilisation de substance (par type de substance et par âge), l’application d’une répartition de la sévérité des troubles de l’utilisation de substances selon trois catégories (léger, modéré et sévère), ainsi que le recours à des taux de traitement, élaborés à partir du jugement d’experts, reflétant la proportion de personnes dans chaque catégorie de sévérité qui devraient avoir accès, seraient susceptibles de chercher et d’éventuellement bénéficier d’un traitement. Des analyses de sensibilité incorporant différentes variations de la répartition de la sévérité et des taux de traitement ont été menées, incluant des ajustements pour la polyconsommation.

Résultats :

L’estimation de la demande de traitements pour l’Australie varie entre un minimum de 411 740 personnes et un maximum de 755 557 personnes. Le paramètre le plus sensible est le taux de recherche de traitement. Étant donné qu’environ 200 000 à 230 000 personnes sont actuellement en traitement, cela représente une réponse à la demande variant entre 26,8% et 56,4%.

Conclusion:

Il n’y a pas suffisamment de traitement en toxicomanie disponible en Australie pour répondre à la demande, en dépit de la capacité relativement élevée de l’Australie de répondre à la demande comparativement à d’autres pays.

Objetivo:

La estimación de la demanda de tratamiento es uno de los elementos importantes en la planificación de los servicios de tratamiento de alcohol y otras drogas. Este documento informa sobre un modelo de demanda-proyección, usados en Australia para estimar la magnitud de la demanda de tratamiento no satisfecha por tipo de droga.

Método:

El modelo incorporó la prevalencia de trastornos por consumo de sustancias (por tipo de droga y edad), la aplicación de una distribución de gravedad, que distribuyó los trastornos por abuso de sustancias en tres categorías de discapacidad: leve, moderada y grave, y la aplicación de tasas de tratamiento derivadas de expertos que reflejan la proporción de personas dentro de las categorías de discapacidad que sería adecuado para, propensos a buscar, y beneficiarse del tratamiento. Se aplicaron análisis de sensibilidad que incorporan variaciones a las distribuciones de gravedad y las tasas de tratamiento, junto con un ajuste para el uso de polifármacos.

Resultados:

La estimación de la demanda de tratamiento para Australia varió entre un mínimo de 411,740 personas y un máximo de 755,557 personas. El parámetro más sensible es la tasa de búsqueda de tratamiento esperada. Dado que alrededor de 200,000 a 230,000 personas están actualmente en tratamiento, esto representa una demanda satisfecha de entre 26.8% y 56.4%.

Conclusión:

No hay suficiente tratamiento de alcohol y drogas disponible para satisfacer la demanda en Australia, a pesar de la relativamente alta demanda de Australia en comparación con otros países.

Geographic Disparities in Availability of Opioid Use Disorder Treatment for Medicaid Enrollees

OBJECTIVE

To examine county-level geographic variation in treatment admissions among opioid treatment programs (OTPs) that accept Medicaid in the continental United States.

DATA SOURCES/STUDY SETTING

Data come from the 2012 National Survey of Substance Abuse Treatment Services.

STUDY DESIGN/DATA COLLECTION

We used local measures of spatial autocorrelation (LISA) analysis to identify (1) clusters of counties with higher and lower than average rates of opioid use disorders and (2) clusters of counties with higher and lower than average treatment admissions among OTPs that accept Medicaid, adjusting for county population size.

PRINCIPAL FINDINGS

Our results reveal several clusters of counties with higher than average rates of opioid use disorder (OUD) and lower than average treatment admissions among OTPs that accept Medicaid. These clusters are highly concentrated in the Southeast region of the country and include Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee.

CONCLUSIONS

Medicaid enrollees in areas in the Southeast have the largest gaps between county-level OUD rates and estimated county-level capacity for treatment, as measured by county-level total treatment admissions among OTPs that accept Medicaid. Policy makers should consider strategies to increase the availability of OTPs with the capacity to serve Medicaid enrollees.

Refining Measurement of Substance Use Disorders Among Women of Child-Bearing Age Using Hospital Records: The Development of the Explicit-Mention Substance Abuse Need for Treatment in Women (EMSANT-W) Algorithm

Substance use disorder (SUD) in women of reproductive age is associated with adverse health consequences for both women and their offspring. US states need a feasible population-based, case-identification tool to generate better approximations of SUD prevalence, treatment use, and treatment outcomes among women. This article presents the development of the Explicit Mention Substance Abuse Need for Treatment in Women (EMSANT-W), a gender-tailored tool based upon existing International Classification of Diseases, 9th Edition, Clinical Modification diagnostic code-based groupers that can be applied to hospital administrative data. Gender-tailoring entailed the addition of codes related to infants, pregnancy, and prescription drug abuse, as well as the creation of inclusion/exclusion rules based on other conditions present in the diagnostic record. Among 1,728,027 women and associated infants who accessed hospital care from January 1, 2002 to December 31, 2008 in Massachusetts, EMSANT-W identified 103,059 women with probable SUD. EMSANT-W identified 4,116 women who were not identified by the widely used Clinical Classifications Software for Mental Health and Substance Abuse (CCS-MHSA) and did not capture 853 women identified by CCS-MHSA. Content and approach innovations in EMSANT-W address potential limitations of the Clinical Classifications Software, and create a methodologically sound, gender-tailored and feasible population-based tool for identifying women of reproductive age in need of further evaluation for SUD treatment. Rapid changes in health care service infrastructure, delivery systems and policies require tools such as the EMSANT-W that provide more precise identification methods for sub-populations and can serve as the foundation for analyses of treatment use and outcomes.

Treatment outcomes for substance use disorder among women of reproductive age in Massachusetts: a population-based approach

INTRODUCTION

Longitudinal patterns of treatment utilization and relapse among women of reproductive age with substance use disorder (SUD) are not well known. In this statewide report spanning seven years we describe SUD prevalence, SUD treatment utilization, and differences in subsequent emergency department (ED) use and post-treatment relapse rates by type of treatment: none, 'acute only' (detoxification/stabilization), or 'ongoing' services.

METHODS

We linked a statewide dataset of hospital discharge, observation stay and ED records with SUD treatment admission records from hospitals and freestanding facilities, and birth/fetal death certificates, in Massachusetts, 2002-2008. We aggregated episodes into individual woman records, identified evidence of SUD and treatment, and tested post-treatment outcomes.

RESULTS

Nearly 150,000 (8.5%) of 1.7 million Massachusetts women aged 15-49 were identified as SUD-positive. Nearly half of SUD-positive women (71,533 or 48.3%) had evidence of hospital or facility-based SUD treatment; among these, 12% received acute care/detoxification only while 88% obtained 'ongoing' treatment. Treatment varied by substance type; women with dual diagnosis and those with opiate use were least likely to receive 'ongoing' treatment. Treated women were older and less likely to have a psychiatric history or chronic illness. Women who received 'acute only' services were more likely to relapse (12.4% vs. 9.6%) and had a 10% higher rate of ED visits post-treatment than women receiving 'ongoing' treatment.

CONCLUSIONS

Many Massachusetts women of reproductive age need but do not receive adequate SUD treatment. 'Ongoing' services beyond detoxification/stabilization may reduce the likelihood of post-treatment relapse and/or reliance on the ED for subsequent medical care.

The association of injury with substance use disorder among women of reproductive age: an opportunity to address a major contributor to recurrent preventable emergency department visits?

OBJECTIVES

Substance use disorder (SUD) among women of reproductive age is a complex public health problem affecting a diverse spectrum of women and their families, with potential consequences across generations. The goals of this study were 1) to describe and compare the prevalence of patterns of injury requiring emergency department (ED) visits among SUD-positive and SUD-negative women and 2) among SUD-positive women, to investigate the association of specific categories of injury with type of substance used.

METHODS

This study was a secondary analysis of a large, multisource health care utilization data set developed to analyze SUD prevalence, and health and substance abuse treatment outcomes, for women of reproductive age in Massachusetts, 2002 through 2008. Sources for this linked data set included diagnostic codes for ED, inpatient, and outpatient stay discharges; SUD facility treatment records; and vital records for women and for their neonates.

RESULTS

Injury data (ICD-9-CM E-codes) were available for 127,227 SUD-positive women. Almost two-thirds of SUD-positive women had any type of injury, compared to 44.8% of SUD-negative women. The mean (±SD) number of events also differed (2.27 ± 4.1 for SUD-positive women vs. 0.73 ± 1.3 for SUD-negative women, p < 0.0001). For four specific injury types, the proportion injured was almost double for SUD-positive women (49.3% vs 23.4%), and the mean (±SD) number of events was more than double (0.72 ± 0.9 vs. 0.26 ± 0.5, p < 0.0001). The numbers and proportions of motor vehicle incidents and falls were significantly higher in SUD-positive women (22.5% vs. 12.5% and 26.6% vs. 11.0%, respectively), but the greatest differences were in self-inflicted injury (11.5% vs. 0.8%; mean ± SD events = 0.19 ± 0.9 vs. 0.009 ± 0.2, p < 0.0001) and purposefully inflicted injury (11.5% vs 1.9%, mean ± SD events = 0.18 ± 0.1 vs. 0.02 ± 0.2, p < 0.0001). In each of the injury categories that we examined, injury rates among SUD-positive women were lowest for alcohol disorders only and highest for alcohol and drug disorders combined. Among 33,600 women identified as using opioids, 2,132 (6.3%) presented to the ED with overdose. Multiple overdose visits were common (mean ± SD = 3.67 ± 6.70 visits). After adjustment for sociodemographic characteristics, psychiatric history, and complex/chronic illness, SUD remained a significant risk factor for all types of injury, but for the suicide/self-inflicted injury category, psychiatric history was by far the stronger predictor.

CONCLUSIONS

The presence of SUD increases the likelihood that women in the 15- to 49-year age group will present to the ED with injury. Conversely, women with injury may be more likely to be involved in alcohol abuse or other substance use. The high rates of injury that we identified among women with SUD suggest the utility of including a brief, validated screen for substance use as part of an ED injury treatment protocol and referring injured women for assessment and/or treatment when scores indicate the likelihood of SUD.

Community context and healthcare quality: the impact of community resources on licensing and accreditation of substance abuse treatment agencies

This study examines variation in healthcare quality among substance abuse treatment agencies. Using an organizations framework, the authors predict that resource advantages benefit certain types of healthcare organizations, especially those located in affluent communities. As a result, levels of licensing and accreditation of substance abuse treatment agencies will differ across United States counties. The authors model these resources at both the organizational and community levels in an effort to understand the variability of licensing and accreditation between agencies and their local contexts. In multivariate models, the findings confirm that organizational characteristics such as private ownership (compared to public ownership), managed care contracts, inpatient and residential programs (compared to outpatient settings), as well as socioeconomic, racial/ethnic, and healthcare system advantage promote higher levels of licensing and accreditation. Public ownership and outpatient settings, as well as socioeconomic, racial/ethnic, and healthcare system disadvantage, are associated with lower levels of licensing and accreditation.

A spatial analysis of community disadvantage and access to healthcare services in the U.S

Ongoing socioeconomic and racial and ethnic gaps in access to healthcare make it vital to examine the relationship between characteristics of communities and their impact on the availability of healthcare services. This study investigates how community-based resource constraints influence the provision of healthcare services in the United States. Drawing on several theoretical frameworks including research in the spatial distribution of healthcare, we compile data on 3141 U.S. counties in order to investigate the argument that gaps in the provision of substance abuse treatment are a function of resource constraints experienced by disadvantaged communities. Our principal aim is to demonstrate that socioeconomic privation, racial and ethnic isolation and limited healthcare infrastructure constrain the provision of substance abuse treatment services. Since prior research shows spatial clustering of socioeconomic privation, racial and ethnic isolation, and healthcare resources, we explicitly model the spatial dimensions of community-based resource disadvantage. Central findings support our chief expectations: counties with greater socioeconomic privation and diminished healthcare infrastructure experienced limited access to substance abuse treatment. Moreover, treatment clusters themselves were significantly related to socioeconomic privation and diminished healthcare infrastructure. Counties with a higher proportion of racial and ethnic minority members, however, did not experience less access to substance abuse treatment, with one exception, although post hoc analyses showed poverty had a moderating effect on race and ethnicity. Study limitations and implications for the organization of treatment resources are discussed.

Unmet need for Substance Abuse Treatment of Adults in Massachusetts

This article presents a methodology to estimate the size and cost of eliminating unmet need for substance abuse treatment services among adults who have clinically significant substance use disorders, and applies the approach to Massachusetts' information. Unmet treatment needs were derived using a statewide household telephone survey of 7,251 Massachusetts residents aged 19 and older conducted in 1996-1997, and an index of treatment mix and cost information from state and Medicaid financial data. The study estimates that 39,450 adult state residents (0.81% of the total sample) had a clinically significant past-year substance use disorder, but had not received treatment in the past year. Providing substance abuse treatment and outreach services to them would have required an additional cost of approximately 109 million dollars (17 dollars per capita), of which the state's payer of last resort, the Massachusetts Department of Public Health Bureau of Substance Abuse Services (BSAS), would need to fund 31 million dollars (5 dollars per capita). The share paid by BSAS (28%) would represent an increase of 42% over its current spending. This paper quantifies an important but sometimes overlooked objective of managed care: to improve access for substance abusers who need but do not seek treatment.

Substance abuse treatment needs and access in the USA: interstate variations

AIMS

This study investigated interstate substance abuse treatment needs and access in the USA.

DESIGN

After assessing the validity of recently developed survey and indicator measures, the study analysed the geographic distribution and nature of state substance abuse treatment needs. Substance abuse treatment utilization index scores were regressed on the need measurements to identify differences among state populations in treatment access.

FINDINGS

The interstate substance abuse treatment need measures had evidence of reliability and construct validity. Treatment needs clustered in stable, distinct geographic patterns. The most severe problems, primarily reflecting alcoholism, were in the west. Drug and alcohol substance use disorders and related problems were not significantly correlated at this level of aggregation. There was evidence of regionalization of the drug-of-choice mix in treatment admissions. Only 21% of the variations in state treatment utilization rates stemmed from the prevalence of substance use disorders and related problems. The biggest treatment gaps were in the south and south-west, regions with large minority populations.

CONCLUSIONS

Development of interstate survey and indicator measures of treatment needs has created new opportunities to broaden our understanding of substance abuse epidemiology and treatment access in the USA. The nature and severity of drug and alcohol problems vary from state to state, but the interstate disparities in treatment services remain even after variations in treatment need have been discounted. Further research is needed to understand the causes of these differences in treatment access.