Health services for women in outpatient substance abuse treatment

Provider perceptions of challenges to identifying women Veterans with hazardous substance use

BACKGROUND

Approximately one-third of women Veterans Health Administration (VHA) users have substance use disorders (SUD). Early identification of hazardous substance use in this population is critical for the prevention and treatment of SUD. We aimed to understand challenges to identifying women Veterans with hazardous substance use to improve future referral, evaluation, and treatment efforts.

METHODS

Design: We conducted a secondary analysis of semi-structured interviews conducted with VHA interdisciplinary women's SUD providers at VA Greater Los Angeles Healthcare System.

PARTICIPANTS

Using purposive and snowball sampling we interviewed 17 VHA providers from psychology, social work, women's health, primary care, and psychiatry.

APPROACH

Our analytic approach was content analysis of provider perceptions of identifying hazardous substance use in women Veterans.

RESULTS

Providers noted limitations across an array of existing identification methodologies employed to identify women with hazardous substance use and believed these limitations were abated through trusting provider-patient communication. Providers emphasized the need to have a process in place to respond to hazardous use when identified. Provider level factors, including provider bias, and patient level factors such as how they self-identify, may impact identification of women Veterans with hazardous substance use. Tailoring language to be sensitive to patient identity may help with identification in women Veterans with hazardous substance use or SUD who are not getting care in VHA but are eligible as well as those who are not eligible for care in VHA.

CONCLUSIONS

To overcome limitations of existing screening tools and processes of identifying and referring women Veterans with hazardous substance use to appropriate care, future efforts should focus on minimizing provider bias, building trust in patient-provider relationships, and accommodating patient identities.

The Pregnancy Recovery Center: A women-centered treatment program for pregnant and postpartum women with opioid use disorder

OBJECTIVE

To evaluate the impact of women-centered substance abuse treatment programming on outcomes among pregnant women with opioid use disorder (OUD).

METHODS

We compared two retrospective cohorts of pregnant women with OUD on buprenorphine maintenance therapy who delivered an infant at the University of Pittsburgh from 2014 to 2016. Cohort 1 was composed of pregnant women who received women-centered OUD treatment services through the Pregnancy Recovery Program (PRC) and Cohort 2 was composed of pregnant women who received buprenorphine at OUD programs without women-centered services (non-PRC). Women-centered outcomes were defined as a) pregnancy-specific buprenorphine dosing, b) prenatal and postpartum care attendance, c) breastfeeding and d) highly effective contraception utilization. Chi-square and t-tests were used to compare outcomes between PRC and non-PRC patients.

RESULTS

Among 248 pregnant women with OUD, 71 (28.6%) were PRC and 177 (71.4%) were non-PRC patients. PRC patients were significantly more likely to initiate buprenorphine during vs. prior to their pregnancy (81.4% vs. 44.2%; p < .01) and have a higher buprenorphine dose at the time of delivery (16.0 mg vs. 14.1 mg; p = .02) compared to non-PRC patients. Likewise, PRC patients were significantly more likely to attend their postpartum visit (67.9% vs. 52.6%; p = .05) and receive a long-acting reversible contraceptive (LARC) method (23.9% vs. 13.0%, p = .03) after delivery compared to non-PRC patients. Finally, PRC patients had a smaller percent decrease in the rate of breastfeeding during their delivery hospitalization (-14.7% vs. -37.1%).

CONCLUSIONS

Incorporating women-centered services into OUD treatment programming may improve gender-specific outcomes among women with OUD.

Adherence trajectories of buprenorphine therapy among pregnant women in a large state Medicaid program in the United States

PURPOSE

Little is known about the longitudinal patterns of buprenorphine adherence among pregnant women with opioid use disorder, especially when late initiation, nonadherence, or early discontinuation of buprenorphine during pregnancy may increase the risk of adverse outcomes. We aimed to identify distinct trajectories of buprenorphine use during pregnancy, and factors associated with these trajectories in Medicaid-enrolled pregnant women.

METHODS

A retrospective cohort study included 2361 Pennsylvania Medicaid enrollees aged 15 to 46 having buprenorphine therapy during pregnancy and a live birth between 2008 and 2015. We used group-based trajectory models to identify buprenorphine use patterns in the 40 weeks prior to delivery and 12 weeks postdelivery. Multivariable multinomial logistic regression models were used to identify factors associated with specific trajectories.

RESULTS

Six distinct trajectories were identified. Four groups initiated buprenorphine during the first trimester of the pregnancy (early initiators): 31.6% with persistently high adherence, 15.1% with moderate-to-high adherence, 10.5% with declining adherence, and 16.7% with early discontinuation. Two groups did not initiate buprenorphine until midsecond or third trimester (late initiators): 13.5% had moderate-to-high adherence and 12.6% had low-to-moderate adherence. Factors significantly associated with late initiation and discontinuation were younger age, non-white race, residents of rural counties, fewer outpatient visits, more frequent emergency department visits and hospitalizations, and lower buprenorphine daily dose.

CONCLUSIONS

Six buprenorphine treatment trajectories during pregnancy were identified in this population-based Medicaid cohort, with 25% of women initiating buprenorphine late during pregnancy. Understanding trajectories of buprenorphine use and factors associated with discontinuation/nonadherence may guide integration of behavioral treatment with obstetrical/gynecological care to improve buprenorphine treatment during pregnancy.

Substance Use Disorder Treatment Services for Women in the Veterans Health Administration

PURPOSE

The present study used national Veterans Health Administration (VHA) facility-level data to examine the extent of women's specialty substance use disorder (SUD) treatment programming in the VHA. In addition, the study compared facilities with women's specialty SUD programming with facilities without to determine whether having this programming was associated with serving other special patient populations, treatment staffing, and breadth of service provision.

METHODS

The study used data from the VHA Program Evaluation and Resource Center's Drug and Alcohol Program Survey, conducted in 2015 (100% response rate among VHA specialty SUD treatment programs). Program responses were calculated at the facility level (n = 140 VHA facilities).

MAIN FINDINGS

The majority of VHA facilities (85%) provided women veterans with SUD-specific individual psychotherapy. However, only 30% of facilities provided SUD-specific groups for women only, and only 14% provided SUD-posttraumatic stress disorder groups for women only in specialty SUD treatment. VHA facilities with greater numbers of specialty SUD treatment staff members, a greater breadth of staff roles, and a broader scope of treatment services, activities, and practices were more likely to provide women-only groups.

CONCLUSIONS

Because the number of women veterans in specialty SUD treatment is likely to continue to grow, these data serve as a benchmark against which future administrations of the Drug and Alcohol Program Survey will document the extent to which VHA services are responsive to their needs.

Identifying and reducing disparities in successful addiction treatment completion: testing the role of Medicaid payment acceptance

BACKGROUND

Medicaid has become the largest payer of substance use disorder treatment and may enhance access to quality care and reduce disparities. We tested whether treatment programs' acceptance of Medicaid payments was associated with reduced disparities between Mexican Americans and non-Latino Whites.

METHODS

We analyzed client and program data from 122 publicly funded treatment programs in 2010 and 112 programs in 2013. These data were merged with information regarding 15,412 adult clients from both periods, of whom we selected only Mexican Americans (n = 7130, 46.3%) and non-Latino Whites (n = 8282, 53.7%). We used multilevel logistic regression and variance decomposition to examine associations and underlying factors associated with Mexican American and White differences in treatment completion. Variables of interest included client demographics; drug use severity and mental health issues; and program license, accreditation, and acceptance of Medicaid payments.

RESULTS

Mexican Americans had lower odds of treatment completion (OR = 0.677; 95% CI = 0.534, 0.859) compared to non-Latino Whites. This disparity was explained in part by primary drug used, greater drug use severity, history of mental health disorders, and program acceptance of Medicaid payments. The interaction between Mexican Americans and acceptance of Medicaid was statistically significant (OR = 1.284; 95% CI = 1.008, 1.637).

CONCLUSIONS

Findings highlighted key program and client drivers of this disparity and the promising role of program acceptance of Medicaid payment to eliminate disparities in treatment completion among Mexican Americans. Implications for health policy during the Trump Administration are discussed.

Gender Comparison in Referrals and Treatment Completion to Residential and Outpatient Alcohol Treatment

BACKGROUND

Residential treatment for alcoholism is associated with high completion rates for clients, yet there appear to be gender disparities in patient referrals and treatment completion rates. We studied whether (A) gender is associated with differential patient placement to outpatient vs. residential treatment facilities and (B) completion rates differ by gender.

METHODS

In this cross-sectional study, we analyzed the admission and discharge data from 185 publicly funded substance abuse treatment facilities across Los Angeles County between 2005 and 2010.

RESULTS

Among the 33,745 studied cases, women were referred to residential treatment facilities less frequently than men (75% vs. 66%). The adjusted results derived from logistic regression models confirmed that females were more likely to be referred to outpatient treatment than to residential treatment facilities (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.05–1.26). In addition, we observed that compared to White/Caucasian patients, all other races were associated with more referral to outpatient facilities (ie, less referral to residential facilities), indicating a racial disparity on the top of the observed gender disparity. However, there was no significant link between gender and treatment completion rates (OR: 0.93, 95% CI: 0.86–1.00).

CONCLUSIONS

Women seem to have treatment completion rates comparable to men, yet they are less likely to be referred to residential treatment facilities. Hence, there still remains a gender disparity in alcoholic patient referrals. Further studies should delineate which specific therapeutic aspects and programmatic components of women-focused treatments are essential to augment positive treatment outcomes.

Women-Centered Drug Treatment Services and Need in the United States, 2002-2009

OBJECTIVES

We examined options and need for women-centered substance use disorder treatment in the United States between 2002 and 2009.

METHODS

We obtained characteristics of facilities from the National Survey of Substance Abuse Treatment Services and treatment need data from the National Survey on Drug Use and Health. We also examined differences in provision of women-centered programs by urbanization level in data from the National Center for Health Statistics 2006 Rural-Urban County Continuum.

RESULTS

Of the 13 000 facilities surveyed annually, the proportion offering women-centered services declined from 43% in 2002 to 40% in 2009 (P < .001). Urban location, state population size, and Medicaid payment predicted provision of such services as trauma-related and domestic violence counseling, child care, and housing assistance (all, P < .001). Prevalence of women with unmet need ranged from 81% to 95% across states.

CONCLUSIONS

Change in availability of women-centered drug treatment services was minimal from 2002 to 2009, even though need for treatment was high in all states.

Exploring Diversification as A Management Strategy in Substance Use Disorder Treatment Organizations

Implementation of the Affordable Care Act (ACA) creates both environmental uncertainties and opportunities for substance use disorder (SUD) treatment providers. One managerial response to uncertainties and emergent opportunities is strategic diversification of various dimensions of organizational activity. This paper explored organizational outcomes related to diversification of funding sources, services offered, and referral sources in a national sample of 590 SUD treatment organizations. Funding diversification was related to higher average levels of census, organization size, and recent expansion of operations. Service diversification was related to higher average levels of use of medication-assisted treatment (MAT), organization size, and expansion. Referral source diversification was related only to greater average use of MAT. Overall, strategic diversification in the three areas explored was related to positive organizational outcomes. Considering alternative strategies of diversification may help position SUD treatment centers to deliver more innovative treatments such as MAT as well as enhance capacity to satisfy current unmet treatment needs of individuals with behavioral health coverage provided under the ACA.

Do cultural and linguistic competence matter in Latinos' completion of mandated substance abuse treatment?

BACKGROUND

Increasing evidence suggests that culturally and linguistically responsive programs may improve substance abuse treatment outcomes among Latinos. However, little is known about whether individual practices or culturally and linguistically responsive contexts support efforts by first-time Latino clients to successfully complete mandated treatment.

METHODS

We analyzed client and program data from publicly funded treatment programs contracted through the criminal justice system in California. A sample of 5,150 first-time Latino clients nested within 48 treatment programs was analyzed using multilevel logistic regressions.

RESULTS

Outpatient treatment, homelessness, and a high frequency of drug use at intake were associated with decreased odds of treatment completion among Latinos. Programs that routinely offered a culturally and linguistically responsive practice-namely, Spanish-language translation-were associated with increased odds of completion of mandated treatment.

CONCLUSIONS

These preliminary findings suggest that concrete practices such as offering Spanish translation improve treatment adherence within a population that is at high risk of treatment dropout.

Workforce diversity in outpatient substance abuse treatment: the role of leaders' characteristics

Although the outpatient substance abuse treatment field has seen an increase in referrals of African American and Latino clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients. Program leaders have significant influence to leverage resources to develop staff diversity. Analysis of panel data from 1995 to 2005 showed that the most significant predictors of diversity were the characteristics of leaders. In particular, programs with managers with racially and ethnically concordant backgrounds and their education level were positively related to the percentage of Latino and African American staff. A high percentage of African American staff was positively associated with managers' tenure, but inversely related to licensed directors. Diversification of the field has increased, yet efforts have not matched increases in client diversity. Implications for health care reform legislation seeking to improve cultural competence through diversification of the workforce are discussed.

The ABLe change framework: a conceptual and methodological tool for promoting systems change

This paper presents a new approach to the design and implementation of community change efforts like a System of Care. Called the ABLe Change Framework, the model provides simultaneous attention to the content and process of the work, ensuring effective implementation and the pursuit of systems change. Three key strategies are employed in this model to ensure the integration of content and process efforts and effective mobilization of broad scale systems change: Systemic Action Learning Teams, Simple Rules, and Small Wins. In this paper we describe the ABLe Change Framework and present a case study in which we successfully applied this approach to one system of care effort in Michigan.

Organizational characteristics that foster early adoption of cultural and linguistic competence in outpatient substance abuse treatment in the United States

Recent years have seen an increased interest in developing culturally and linguistically responsive systems of care in substance abuse treatment in the United States. This study examines the extent to which external and internal organizational pressures contributed to the degree of adoption of culturally and linguistically responsive practices in the nation's outpatient substance abuse treatment system early in the period of development of this system of care. Findings show that a higher degree of adoption of culturally competent practices was most likely in treatment programs with high dependence on external funding and regulation. Internally, programs with a larger number of professionals were associated with the lowest degree of adoption, while managers' cultural sensitivity contributed significantly to a high degree of adoption of these responsive practices. Considering the passage of recent legislation enforcing the use of cultural and linguistic competence in health care, implications of these baseline findings on early adoption patterns are discussed for future research and health care policy evaluation.

Adoption and utilization of sexually transmitted infections testing in outpatient substance abuse treatment facilities serving high risk populations in the U.S

BACKGROUND

Although adoption and utilization of sexually transmitted infection (STI) testing is a cost effective public health intervention, it is inconsistently offered or referred out for by outpatient substance abuse treatment (OSAT) programs where at-risk racial/ethnic and sexual minorities receive services.

METHODS

We explored the organizational adoption and client utilization of STI testing using a nationally representative sample of OSAT facilities in the U.S. in 2005 (N=566). Data missing at random was imputed and the resulting database was analysed using multivariate Tobit and logistic regressions.

RESULTS

The analyses suggest that private non-profit facilities, which are the largest providers of OSAT treatment are less likely than public facilities to offer STI testing or to report adequate client utilization rates. Higher utilization was instead associated with professionally accredited facilities, and with facilities whose majority of clients were Latino/a, reported a history of treatment, stayed in treatment longer, or received case management.

CONCLUSION

While OSAT facilities are poised to be primary intervention points for diagnosis and treatment of STIs, only a segment of these facilities provide this preventive practice or manage to refer clients out. As such, U.S. health care policy should ensure the adoption and comprehensive utilization, particularly among high risk clients, of this cost-effective prevention strategy in OSAT admission protocols.

Managerial capacity and adoption of culturally competent practices in outpatient substance abuse treatment organizations

The field of cultural competence is shifting its primary emphasis from enhancement of counselors' skills to management, organizational policy, and processes of care. This study examined managers' characteristics associated with adoption of culturally competent practices in the nation's outpatient substance abuse treatment field. Findings indicate that in 1995, supervisors' cultural sensitivity played the most significant role in adopting practices, such as matching counselors and clients based on race and offering bilingual services. Staff's exposure to cross-cultural training increased from 1995 to 2005. In this period, positive associations were found between managers' cultural sensitivity and connection with the community and staff receiving cross-cultural training and the number of training hours completed. However, exposure to and investment in this training were negatively correlated with managers' formal education. Health administration policy should consider the extent to which the decision makers' education, community involvement, and cultural sensitivity contribute to building culturally responsive systems of care.

Influence of ownership on access in outpatient substance abuse treatment

Marked changes in ownership and control in substance abuse treatment delivery have garnered the attention of providers and policymakers alike. The proliferation of private for-profit providers and the shift to a delivery system that may be more explicitly influenced by financial incentives are of particular concern for this vulnerable population. This work empirically addresses how treatment unit ownership affected access and retention between 1995 and 2005 in the United States. Regressions show statistically significant associations between unit ownership and both restricted treatment access and shortening of treatment duration for financial reasons. In comparison to private nonprofit and public units, private for-profit units were less likely to provide initial treatment access and reported shortened treatment for a greater percentage of clients unable to pay. Other organization characteristics, such as methadone-maintenance programs and managed care participation, also were associated with limiting treatment accessibility. While this work does not determine the underlying motivation behind access limitations, continued shifts in ownership structure should heighten the attention of policymakers.

Organizational determinants of outpatient substance abuse treatment duration in women

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.

Tailored treatment in the outpatient substance abuse treatment sector: 1995–2005

Interest in improving the quality of addiction treatment has led to the development of clinical paradigms that emphasize the principle of tailored care-matching treatments to the specific needs of each client or client subgroup. This work analyzes how trends in the provision of tailored treatment practices (TTPs) have changed between 1995 and 2005 across outpatient substance abuse treatment (OSAT) programs in the United States. Categories of interest include measures to capture needs assessment and treatment planning activities, treatment offerings for special populations, and case management activities. Results show that TTPs have diffused in an uneven fashion in the population of OSAT programs between 1995 and 2005. Specifically, needs assessment/treatment planning and case management remain a relatively common practice among OSAT programs, while treatment for special populations (especially same-race therapy) is less widely practiced and, indeed, experienced some decline over the study period. This trend is troublesome given that minority clients constitute a large proportion of those utilizing OSAT programs.

Tailoring of outpatient substance abuse treatment to women, 1995-2005

BACKGROUND

Tailoring substance abuse treatment to women often leads to better outcomes. Previous evidence, however, suggests limited availability of such options.

OBJECTIVES

This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women and to identify unit and contextual factors associated with these practices.

RESEARCH DESIGN

Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N = 566 in 2005). Comparisons of weighted means between waves indicate which practices changed over time. Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women.

MEASURES

Tailoring to women was measured as availability of prenatal care, child care, single sex therapy, and same sex therapists, and the percentage of staff trained to meet female clients' needs.

RESULTS

Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Proportion of female clients, total number of clients, methadone status, and private and government managed care were associated with higher odds of tailoring to women. For-profit facilities, which became more prevalent during the study period, had lower odds than other units of tailoring treatment to women.

CONCLUSIONS

Some key aspects of OSAT tailoring to women decreased significantly in the last decade. Managed care contracts may offer 1 mechanism for counteracting these trends.

The role of organization and management in substance abuse treatment: Review and roadmap

To develop an understanding as to why there exists a seemingly wide gap between research and practice in the field of substance abuse treatment and, more important, to understand how this gap can be closed, researchers have focused their attention on the role of organizational and management factors in the delivery of treatment services. This article's overarching goal is to stimulate research and interventions that focus on these factors so as to improve the standards and outcomes of care in substance abuse treatment. Part 1 introduces the key assumptions and perspectives that guide organization and management research. Part 2 selectively reviews empirical studies that examine relationships between treatment programs' use of research-based treatment practices and organization and management factors. The article concludes with a discussion of the next important steps for research and policy.