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

Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis

Background

Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations.

Methods

All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes.

Results

Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (β + 0.90 days, CI +0.68-1.12) and costs (β + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70).

Conclusions

Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.

Community-Based Services for Hospitalized Patients With Serious Injection-Related Infections in Alabama: A Brief Report

Injection-related infections continue to rise, particularly in the South. People who inject drugs are increasingly utilizing hospital services for serious injection-related infections but may be discharged to areas without harm reduction services. We explored the availability and travel time to services for HIV and substance use in Alabama.

Telemedicine for unhealthy alcohol use in adults living with HIV in Alabama using common elements treatment approach: A hybrid clinical efficacy-implementation trial protocol

Background

Unhealthy alcohol use is an unaddressed barrier to achieving and maintaining control of the human immunodeficiency virus (HIV) epidemic. Integrated screening, treatment of common behavioral and mental health comorbidities, and telemedicine can improve alcohol treatment and HIV clinical and quality of life outcomes for rural and underserved populations.

Objective

In a randomized controlled clinical trial, we will evaluate the effectiveness and implementation of telephone-delivered Common Elements Treatment Approach (T-CETA), a transdiagnostic cognitive behavioral therapy protocol, on unhealthy alcohol use, HIV, other substance use and mental health outcomes among predominantly rural adults with HIV receiving care at community clinics in Alabama.

Methods

Adults with HIV receiving care at four selected community clinics in Alabama will receive a telephone-delivered alcohol brief intervention (BI), and then be assigned at random (stratified by clinic and sex) to no further intervention or T-CETA. Participants will be recruited after screening positively for unhealthy alcohol use or when referred by a provider. The target sample size is 308. The primary outcome will be change in the Alcohol Use Disorder Identification Test (AUDIT) at six- and 12-months post-enrollment. Additional outcomes include HIV (retention in care and viral suppression), patient-reported mental health (anxiety, depression, posttraumatic stress), and quality of life. A range of implementation measures be evaluated including T-CETA provider and client acceptability, feasibility, cost and cost-effectiveness.

Conclusions

This trial will inform alcohol treatment within HIV care programs, including the need to consider comorbidities, and the potential impact of alcohol interventions on HIV and quality of life outcomes.

Understanding low treatment seeking rates for alcohol use disorder: A narrative review of the literature and opportunities for improvement

Despite a well-documented global burden of disease attributable to alcohol use disorder (AUD), treatment seeking rates remain low. In this qualitative literature review, we address treatment seeking for AUD from a host of perspectives and summarize the literature on key factors. First, we summarize the rates of alcohol treatment seeking across various epidemiological surveys, spanning decades. Second, we discuss the definition of treatment seeking and 'what' is typically considered formal treatment. Third, we consider timing and discuss 'when' individuals are most likely to seek treatment. Fourth, we review the literature on 'who' is most likely to seek treatment, including demographic and clinical correlates. Fifth, we address the critical question of 'why' so few people receive clinical services for AUD, relative to the number of individuals affected by the disorder, and review barriers to treatment seeking at the treatment- and person-levels of analysis. Finally, we identify opportunities to improve treatment seeking rates by focusing on tangible points of intervention. Specifically, we recommend a host of adaptations to models of care including efforts to make treatment more appealing across stages of AUD severity, accept a range of health-enhancing drinking goals as opposed to an abstinence-only model, educate providers and consumers about evidence-based behavioral and pharmacological treatments, and incentivize the delivery of evidence-based services.

County-level access to opioid use disorder medications in medicare Part D (2010-2015)

OBJECTIVE

To identify geographic disparities in access to opioid use disorder (OUD) treatment medications and county demographic and economic characteristics associated with access to buprenorphine and oral naltrexone prescribers in Medicare Part D.

DATA SOURCES/STUDY SETTING

We utilized data from the Medicare Part D Prescription Drug Event Standard Analytic File (2010-2015).

STUDY DESIGN/DATA COLLECTION

We used logistic regression to examine county-level access to OUD medication prescribers.

PRINCIPAL FINDINGS

There was a 5.6 percentage point increase in counties with access to an OUD prescriber over the study period. However, in 2015, 60 percent of US counties lacked access to a Medicare Part D buprenorphine prescriber and over 75 percent lacked access to an oral naltrexone prescriber. Increased access to OUD prescribers was largely concentrated in urban counties. Results of logistic regression indicate regional differences and potential racial disparities in access to OUD prescribers.

CONCLUSIONS

To improve access to buprenorphine and naltrexone treatment for Medicare Part D enrollees, CMS may consider implementing educational and training initiatives focused on OUD treatment, offering training to obtain a buprenorphine waiver at no cost to providers, and sending targeted information to providers in low OUD treatment capacity 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.

Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study

OBJECTIVE

To assess the relationship of restrictions on Medicaid benefits for addiction treatment to Medicaid acceptance among addiction treatment programs.

DATA SOURCES

We collected primary data from the 2013-2014 wave of the National Drug Abuse Treatment System Survey.

STUDY DESIGN

We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs.

DATA COLLECTION

Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine.

PRINCIPAL FINDINGS

Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states.

CONCLUSIONS

Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.

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.

The role of consumer perspectives in estimating population need for substance use services: a scoping review

Background

A growing body of research assesses population need for substance use services. However, the extent to which survey research incorporates expert versus consumer perspectives on service need is unknown. We conducted a large, international review to (1) describe extant research on population need for substance use services, and the extent to which it incorporates expert and consumer perspectives on service need, (2) critically assess methodological and measurement approaches used to study consumer-defined need, and (3) examine the potential for existing research that prioritizes consumer perspectives to inform substance use service system planning.

Methods

Systematic searches of seven databases identified 1930 peer-reviewed articles addressing population need for substance use services between January 1980 and May 2015. Empirical studies (n = 1887) were categorized according to source(s) of data used to derive population estimates of service need (administrative records, biological samples, qualitative data, and/or quantitative surveys). Quantitative survey studies (n = 1594) were categorized as to whether service need was assessed from an expert and/or consumer perspective; studies employing consumer-defined need measures (n = 217) received further in-depth quantitative coding to describe study designs and measurement strategies.

Results

Almost all survey studies (96%; n = 1534) used diagnostically-oriented measures derived from an expert perspective to assess service need. Of the small number (14%, n = 217) of survey studies that assessed consumer’s perspectives, most (77%) measured perceived need for generic services (i.e. ‘treatment’), with fewer (42%) examining self-assessed barriers to service use, or informal help-seeking from family and friends (10%). Unstandardized measures were commonly used, and very little research was longitudinal or tested hypotheses. Only one study used a consumer-defined need measure to estimate required service system capacity.

Conclusions

Rhetorical calls for including consumer perspectives in substance use service system planning are belied by the empirical literature, which is dominated by expert-driven approaches to measuring population need. Studies addressing consumer-defined need for substance use services are conceptually underdeveloped, and exhibit methodological and measurement weaknesses. Further scholarship is needed to integrate multidisciplinary perspectives in this literature, and fully realize the promise of incorporating consumer perspectives into substance use service system planning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2153-z) contains supplementary material, which is available to authorized users.

Acceptability of HIV Testing Sites Among Rural and Urban African Americans Who Use Cocaine

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate that rural AA who use cocaine have lower odds of viewing local health departments (OR = 0.09, 95 % CI = 0.03-0.21), physician offices (OR = 0.19, 95 % CI = 0.09-0.42), and drug use treatment centers (OR = 0.49; 95 % CI = 0.30-0.80) as acceptable relative to their urban counterparts. The findings have implications for further targeting HIV testing toward AAs who use of cocaine, particularly those residing in the rural South.

Barriers and Facilitators to Substance Use Treatment in the Rural South: A Qualitative Study

PURPOSE

Little qualitative research has examined factors associated with care in substance abuse treatment agencies in Southeastern rural communities. This study explored client- and agency stakeholder-perceived barriers and facilitators to substance use treatment delivery in southeastern rural communities.

METHODS

Group and individual interviews were conducted with 40 key stakeholders and 40 clients at 9 substance abuse agencies serving rural communities in a southeastern state. Qualitative thematic analysis was used to identify perceived barriers and facilitators to substance abuse services in rural communities.

FINDINGS

Four primary themes emerged from the client and stakeholder interviews as both barriers and facilitators: availability of services for individuals with substance use disorders; access to the current technology for client services and agency functioning; cost of services; and stigma.

CONCLUSIONS

This study identifies novel barriers and facilitators to substance use care in the rural South and highlights essential areas for consideration when developing and implementing substance use care in this geographic region. These findings can be used as guidelines to provide better care to individuals with substance use disorders living in rural communities.

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.

Emergency commitment of people residing in assisted living facilities

The objective of this study was to describe emergency commitment of people from assisted living facilities (ALFs) and to discuss relevant policy issues. This study used statewide, archival emergency commitment data from July 2000 through June 2008. During the 1 year from July 07 through June 08 there were 3,061 people with 4,163 emergency commitments from ALFs. Some individuals had more than one emergency commitment during the year, with 20% having between 2 and 9 emergency commitments from ALFs. Some of these individuals also had substantial numbers of emergency commitments in the 7 years from July 2000 through June 2007. Discussed are possible factors related to emergency commitment from ALFs and the need for additional research on these topics. This includes availability of mental health services for these populations, the role of client characteristics, and how licensing of ALFs relates to emergency commitment of ALF residents.

Correlates of participation in peer recovery support groups as well as voluntary and mandated substance abuse treatment among rural and urban probationers

This study explores the correlates of probationers' participation in 12-step programs, voluntary treatment, and mandated treatment, with respect to the geographic location of where the services are being provided as the primary covariate of interest. Data were derived from face-to-face interviews with rural and urban probationers (N = 1,464). Results of the three logistic regression models suggested that even when all the covariates are taken into account, urban probationers were significantly more likely to have been involved in 12-step programs, voluntary treatment, and mandated treatment over their lifespan. Despite high levels of self-reported substance use among all participants, treatment services were underused by rural probationers. These data suggest that individuals residing in rural communities may face additional barriers to receiving treatment services and that criminal involvement is associated with participation in peer recovery support groups and treatment. Future studies can investigate criminal involvement as an avenue to enhance recovery and how to overcome treatment barriers in rural areas.

Barriers to the implementation of medication-assisted treatment for substance use disorders: the importance of funding policies and medical infrastructure

Despite growing interest in the use of evidence-based treatment practices, adoption of pharmacotherapies for treating substance use disorders (SUDs) remains modest. Using data from telephone interviews with 250 administrators of publicly funded SUD treatment programs, this study estimated a model of adoption of medication assisted treatment (MAT) for SUDs and examined the relative importance of regulatory, cultural, medical resource, patient-level, and funding barriers to MAT implementation. MAT-adopting programs had significantly greater medical resources, as measured by the employment of physicians and nurses, than non-adopting programs. Administrators of non-adopting programs were asked to rate the importance of 18 barriers to MAT implementation. The most strongly endorsed barriers were regulatory prohibitions due to the program's lack of medical staff, funding barriers to implementing MAT, and lack of access to medical personnel with expertise in delivering MAT. Barriers related to insufficient information about MAT and unsupportive staff attitudes were not widely endorsed. These findings suggest that efforts to promote the implementation of MAT that are inattentive to funding barriers and weaknesses in medical infrastructure may achieve sub-optimal results.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Patterns in admission delays to outpatient methadone treatment in the United States

Waiting lists for methadone treatment have existed in many U.S. communities, but little is known nationally about what patient and service system factors are related to admission delays that stem from program capacity shortfalls. Using a combination of national data sources, this study examined patterns in capacity-related admission delays to outpatient methadone treatment in 40 U.S. metropolitan areas (N = 28,920). Patient characteristics associated with admission delays included racial/ethnic minority status, lower education, criminal justice referral, prior treatment experience, secondary cocaine or alcohol use, and co-occurring psychiatric problems. Injection drug users experienced fewer delays, as did self-pay patients and referrals from health care and addiction treatment providers. Higher community-level utilization of methadone treatment was associated with delay, whereas delays were less common in communities with higher utilization of alternative modalities. These findings highlight potential disparities in timely admission to outpatient methadone treatment. Implications for improving treatment access and service system monitoring are discussed.

Emergency commitment from nursing homes

PURPOSE

The purpose of this study was to describe emergency commitment of residents from nursing homes and to discuss relevant policy issues.

DESIGN AND METHODS

This study used statewide, archival emergency commitment data from July 2000 through June 2008. These data are created by entering data from paper emergency commitment initiation forms of law enforcement, mental health professionals, and judges submitted by facilities as required by Florida law.

RESULTS

During the 1 year from July 2007 through June 2008 there were 898 residents of Florida nursing homes with a total of 1032 emergency commitments. Some individuals had more than one emergency commitment from a nursing home during the year, with 9% having between two and five emergency commitments. One-third of the emergency commitments were for residents younger than 65. Some of these individuals also had substantial numbers of emergency commitments in the 7 years from July 2000 through June 2007.

IMPLICATIONS

There are facility, client, and regulatory factors that can be addressed to reduce the inappropriate usage of emergency commitments in nursing homes.

Rurality, region, ethnic community make-up and alcohol use among rural youth

PURPOSE

As the most widely used substance among adolescents in the United States, alcohol remains a critical public health issue. The majority of research in this area has focused on individual-level variables. This study examined the contextual effects of rurality, geographic region, and community ethnicity in the prediction of alcohol use among adolescent youth.

METHOD

Participants were 7th-12th grade students from a sample of 260 rural communities across the United States, with oversampling for predominantly Mexican American and African American communities. The total sample comprised 213,225 students. Multilevel modeling was used to estimate both individual and contextual effects for use of alcohol and getting drunk.

FINDINGS

Those living in more rural communities were somewhat more likely to have used alcohol and gotten drunk than their less rural counterparts. Consistent with a trend toward a narrowing gender gap across a number of substances, gender differences in alcohol use were not large, except in the South. A minority in a community, eg, a white student in an African American community, had greater risk for alcohol use and getting drunk.

CONCLUSIONS

Models of alcohol use among rural youth that include only individual-level variables are likely to result in misleading results. While students from varying levels of rurality may not differ substantially from one another, geographic region and minority status within communities are likely to interact with individual-level variables, resulting in unique patterns of alcohol use and getting drunk.

Availability of outpatient substance use disorder treatment programs in the United States

The purpose of this study was to examine the availability of outpatient substance use disorder (SUD) treatment programs in the United States. A geographic information system (GIS) was used to spatially locate outpatient SUD treatment programs, calculate areas, and determine population density within specific areas. Urban areas were mapped using data from the US Census (2000). Addresses of outpatient SUD treatment programs were obtained from the Facility Locator Web site of the Substance Abuse and Mental Health Services Administration. A 15-mile service catchment around each outpatient SUD treatment program was drawn. The amount of urban area not covered by the service catchment represents the underserved. Total underserved urban area and population without access was computed for each state. Significant variability of underserved urban area and population was observed across the states. Moderate correlations among area and population suggest that some states are more effective in locating SUD treatment programs than other states.

Predictors of substance abuse treatment entry among rural illicit stimulant users in Ohio, Arkansas, and Kentucky

Illicit drug use in the rural United States is increasingly common, yet little is known about drug users' treatment-seeking behaviors. This study identifies predictors of substance abuse treatment entry over 24 months among 710 illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Active users of powdered cocaine, crack cocaine, and/or methamphetamine (MA) were recruited using respondent-driven sampling. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months. Data were analyzed using the Cox proportional hazards model. The paper is informed by the Anderson-Newman Model. Overall, 18.7% of the sample entered treatment. Ohio or Kentucky residence, perceived need for substance abuse treatment, higher Addiction Severity Index (ASI) legal problem composite scores, prior substance abuse treatment, and tranquilizer use were positively associated with treatment entry. Nondaily crack cocaine users and marijuana users were less likely to enter treatment. The findings can help inform rural substance abuse treatment program development and outreach.

Interpersonal violence exposure and alcohol treatment utilization among medical inpatients with alcohol dependence

The goal of this study was to examine the association between interpersonal violence exposure and utilization of alcohol treatment after medical hospitalizations among adults with alcohol dependence. We analyzed data collected from a prospective cohort of 238 adults with alcohol dependence who were inpatients in a large urban hospital. Participants who reported interpersonal violence victimization had 1.6 times the odds (adjusted odds ratio = 1.64, 95% confidence interval = 0.92-2.91) of receiving alcohol treatment during the year after hospitalization compared to participants with no violence exposure. Recent (past 3 months) exposure to violence was not more strongly related to receipt of treatment than any lifetime violence exposure. Results suggest that a history of interpersonal violence victimization may be associated with an increased odds of alcohol treatment utilization following a medical hospitalization. Therefore, clinicians should be optimistic about identifying and referring patients who have experienced interpersonal violence to alcohol treatment. Moreover, given the potentially high prevalence of interpersonal violence exposure among inpatient populations at large urban hospitals, alcohol treatment providers should develop methods to address both alcohol dependence and violence recovery.

Syringe-Exchange Programs and HIV Prevention

Injection drug users and their sexual partners and children represent an increasing proportion of Americans living with HIV or AIDS. Syringe-exchange programs (SEPs), which are based on the theory of harm reduction, are effective in preventing the transmission of HIV and other pathogens through injection drug use. Most programs also serve as gateways to other vital medical services. Yet SEPs remain controversial. This article describes the controversy, considers the evidence, and discusses the nursing implications.

Need and non-need factors associated with addiction treatment utilization in a cohort of homeless and housed urban poor

BACKGROUND

Research on addiction treatment utilization in indigent samples mainly has been retrospective, without measures of addictive consequences, social network influences, and motivation. Prospective assessment of factors influencing utilization could inform policy and clinical care.

OBJECTIVE

We sought to identify factors associated with utilization of addiction treatment and mutual help groups among substance-dependent persons with high rates of homelessness.

RESEARCH AND METHODS

This was a prospective cohort of patients detoxified from alcohol or drugs at baseline who were followed for 2 years in a randomized clinical trial of linkage to primary care (n = 274). Outcomes included utilization of Inpatient/Residential, Outpatient, Any Treatment, and Mutual Help Groups. Predictor variables in longitudinal regression analyses came from the literature and clinical experience, organized according to theoretical categories of Need, and non-Need (eg, Predisposing and Enabling).

RESULTS

Many subjects used Inpatient/Residential (72%), Outpatient (62%), Any Treatment (88%) or Mutual Help Groups (93%) at least once. In multivariable analyses, addictive consequences (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.12-1.71), motivation (OR 1.32, 95% CI 1.09-1.60), and female gender (OR 1.80, 95% CI 1.13-2.86) were associated with most treatment types (ORs are for Any Treatment). Homelessness was associated with Residential/Inpatient (for Chronically Homeless vs. Housed, OR 1.75, 95% CI 1.04-2.94). Living with one's children (OR 0.51, 95% CI 0.31-0.84) and substance-abusing social environment (OR 0.65, 95% CI 0.43-0.98) were negatively associated with Any Treatment.

CONCLUSIONS

In this cohort of substance-dependent persons, addictive consequences, social network variables, and motivation were associated with treatment utilization. Non-need factors, including living with one's children and gender, also were significant.

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.