State Substance Abuse Treatment Gaps

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.

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.

Disparities in Substance Abuse Treatment Utilization Among Women with Intellectual Disability

Despite concerns about health disparities among women with intellectual disabilities, little is known about substance abuse treatment access in this population. Using standardized performance measures, treatment initiation and engagement were examined retrospectively for women aged 18 to 64 (N = 3,752), men with (N = 5,732) and women without intellectual disability (N = 493,446). Logistic regression models of utilization were conducted. Women in the sample were less likely than men in the sample or women without intellectual disability to utilize treatment, suggesting both gender-related and disability-related barriers. Policy and practice implications for improving the health and welfare of women with intellectual disabilities are discussed.

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.

Demographic and clinical characteristics of people with intellectual disabilities with and without substance abuse disorders in a Medicaid population

Little is known about the demographic and clinical characteristics of people with intellectual disabilities and substance abuse problems. Drawing on health care billing claims for people with Medicaid coverage aged 12-99 years, the characteristics of people with intellectual disability and a history of substance abuse (N=9,484) were explored and compared with people with intellectual disability but without substance abuse. Age- and/or gender-adjusted odds ratios were derived from logistic regression analyses to consider differences in demographic and clinical diagnoses. People with intellectual disability and substance abuse constituted 2.6% of all people with intellectual disability, most of whom had a diagnosis of mild or moderate intellectual disability. People with intellectual disability and substance abuse problems were, on average, 2 years older than the comparison group and less likely to be White. The sample was more likely than the comparison group to have serious mental illness or depression and substance abuse-related disorders were not prevalent. These data provide a comparison point for existing studies of mental health diagnoses as well as new information about substance abuse disorders. Implications relate to the identification of substance abuse among people with intellectual disabilities as well as the establishment of demographic and clinical correlates.

Medicaid-covered alcohol and drug treatment use among people with intellectual disabilities: evidence of disparities

For some, community inclusion facilitates access to alcohol and drugs and, therefore, the potential for developing substance abuse disorders. However, little is known about substance abuse treatment use among people with intellectual disabilities. Using standardized performance measures, substance abuse treatment utilization was examined for Medicaid-covered people with intellectual disabilities and substance abuse (N=9,484) versus people without intellectual disabilities (N=915,070). The sociobehavioral model of healthcare use guides multivariate logistic regression analyses of substance abuse treatment utilization patterns, revealing disability-related disparities. Factors associated with utilization included being non-White, living in a nonurban area, having a serious mental illness, and living in a state with a generous Medicaid plan for substance abuse treatment. Implications relate to health policy, service delivery patterns, and the need for cross-system collaboration in the use of integrated treatment approaches.

Not Immune: Access to Substance Abuse Treatment Among Medicaid-Covered Youth With Mental Retardation

Youth with mental retardation* (MR) have experienced increasing levels of participation in community life over the last 30 years. This freedom has facilitated access to community life beyond school settings; it has also created the potential for alcohol and drug use and for the development of substance abuse (SA). Little is known about access to SA treatment for youth with MR—an especially vulnerable population. Through the application of a set of standardized performance measures, this study examines SA treatment access among youth aged 12 to 21 with and without MR ( N = 150,009). Guided by Andersen’s sociobehavioral model of health care utilization, multivariate logistic regression analyses modeled SA treatment initiation and engagement. Youth with MR and SA were less likely to initiate or engage in treatment. Engagement among youth with MR and SA was associated with being male and/or non-White. Implications relate to a need for improved treatment access for youth with MR and SA through cross-system collaboration.

Filling service gaps: Providing intensive treatment services for offenders

Consistent with the few studies that have previously examined treatment prevalence and access in the adult and juvenile justice systems, the recent National Criminal Justice Treatment Practices (NCJTP) survey indicated that there is a particular need to expand intensive treatment modalities for offenders in both institutional and community corrections settings. Applying multilevel modeling techniques to NCJTP survey data, this study explores conditions and factors that may underlie the wide variation among states in the provision of intensive treatment for offenders. Results indicate that states' overall rates of substance abuse and dependence, funding resources, and the state governor's political party affiliation were significantly associated with intensive treatment provision. Numerous factors that have been implicated in recent studies of evidence-based practice adoption, including state agency executives' views regarding rehabilitation, agency culture and climate, and other state-level measures (e.g., household income, crime rates, expenditures on treatment for the general population) were not associated with treatment provision. Future research should examine further variations in offenders' service needs, the role of legislators' political affiliations, and how other factors may interact with administrator characteristics in the adoption and expansion of intensive treatment services for offenders.

Ethics in substance use disorder treatment

The coming decades will see exciting breakthroughs in the treatment of SUDs, such as further elucidation of the genetic mechanisms of addiction. Yet if the past is any guide to the future, each new discovery will bring with it new challenges to the core ethical obligations of honoring informed consent, protecting confidentiality, and respecting justice, while also protecting the public from harm and ensuring the good of the individual patient. For the emerging scientific shift to a biobehavioral model of addiction to transform cultural attitudes and enhance treatment and research will require the scientifically rigorous and ethically sound agency of ethicists and addiction professionals to influence public policy. The growing body of neurobiologic evidence that contests traditional assumptions about free will and responsibility will evoke more deliberate and nuanced approaches to informed consent and treatment participation and dispute the forensic orientation in drug policy. If this unprecedented paradigm change can influence health care decision making in a reasoned and balanced fashion, there is real hope that the cultural stigma, which has warranted highly stringent confidentiality protections, and the disenfranchisement underlying health disparities in addiction treatment may move in the direction of compassionate and competent care for all those who suffer from addiction.

Adolescent substance abuse treatment resource allocation in rural and frontier conditions: the impact of including organizational readiness to change

CONTEXT

Rural and frontier states are significantly affected by substance abuse and poverty. The high rate of substance abuse coupled with high levels of dependence on state-funded treatment systems places a burden on rural treatment systems and makes resource allocation a central planning issue.

PURPOSE

The goal of this study was to combine substance abuse treatment need data with organizational readiness to change data to create a rank-ordered listing of residential treatment providers to answer the following questions: Do program priority rankings change when organizational readiness to change is included in a need-based resource allocation algorithm?

METHODS

Three methodological procedures were used to determine program priority rankings among 14 residential adolescent treatment programs in 8 Wyoming counties: (1) a social indicators analysis of crime data, (2) synthetic estimates of substance abuse treatment need, and (3) analysis of organizational change data from the directors and staff at adolescent residential treatment programs.

FINDINGS

Program need rankings based on crime data and synthetic estimates of substance abuse treatment need shifted when organizational readiness to change data was added to the algorithm.

CONCLUSIONS

There is much to be gained from considering organizational readiness to change when selecting programs for funding. It plays a central role in the successful diffusion of evidence-based practices within and among programs. Including this measure in the resource allocation process can help planners identify programs that will be more apt to adopt a best practice. This is critical for making decisions about where to allocate scarce treatment resources.

Utilization and cost of mental health, substance abuse, and medical services among at-risk drinkers

The objective of this research was to examine whether users of mental health or substance abuse (MH/SA) services incurred greater costs for non-MH/SA services than nonusers of MH/SA services. Two years of health care utilization data were collected on 443 at-risk drinkers from six southern U.S. states. We then examined predictors of using MH/SA services and costs associated with non-MH/SA services. The results showed that use of MH/SA services was associated with female gender, military service, health insurance, and not being employed full-time. Unadjusted analyses indicated that non-MH/SA service costs were significantly higher among MH/SA service users than nonusers. However, this association did not endure in multivariable models. In fact, emergency department costs were significantly lower among MH/SA users. It is commonly assumed that users of MH/SA services are also heavy users of other medical services. Through multivariable models, this study found that overall costs of non-MH/SA services were similar between users and nonusers of MH/SA services.

Racial and ethnic diversity among a heroin and cocaine using population: treatment system utilization

Knowledge about the meanings and consequences of behaviors associated with drug use among diverse populations is essential for developing effective public health and clinical strategies. In this study we identify racial/ethnic variations in patterns of drug use, Addiction Severity Index (ASI) scores, response to intervention, concordance between self-report of drug use and biochemical confirmation, and treatment system contacts in a sample of 1175 out-of-treatment cocaine and heroin users drawn from a trial of brief motivation in the outpatient clinics of an inner-city academic hospital. Key differences were identified in drug of choice, in all of the ASI domains except medical, in validity of self-report of use, and in rate of treatment contact. Differences related to race and ethnicity should be evaluated to determine needs for a variety of substance abuse treatment modalities, assure timely access to culturally competent care, and develop policies that are tailored to real conditions.

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.