Racial-ethnic disparities in substance abuse treatment: the role of criminal history and socioeconomic status

Lost in transition: A protocol for a retrospective, longitudinal cohort study for addressing challenges in opioid treatment for transition-age adults

BACKGROUND

In the United States, there has been a concerning rise in the prevalence of opioid use disorders (OUD) among transition-age (TA) adults, 18 to 25-years old, with a disproportionate impact on individuals and families covered by Medicaid. Of equal concern, the treatment system continues to underperform for many young people, emphasizing the need to address the treatment challenges faced by this vulnerable population at a pivotal juncture in their life course. Pharmacotherapy is the most effective treatment for OUD, yet notably, observational studies reveal gaps in the receipt of and retention in medications for opioid use disorder (MOUD), resulting in poor outcomes for many TA adults in treatment. Few current studies on OUD treatment quality explicitly consider the influence of individual, organizational, and contextual factors, especially for young people whose social roles and institutional ties remain in flux.

METHODS

We introduce a retrospective, longitudinal cohort design to study treatment quality practices and outcomes among approximately 65,000 TA adults entering treatment for OUD between 2012 and 2025 in New York. We propose to combine data from multiple sources, including Medicaid claims and encounter data and a state registry of substance use disorder (SUD) treatment episodes, to examine three aspects of OUD treatment quality: 1) MOUD use, including MOUD option (e.g., buprenorphine, methadone, or extended-release [XR] naltrexone); 2) adherence to pharmacotherapy and retention in treatment; and 3) adverse events (e.g., overdoses). Using rigorous analytical methods, we will provide insights into how variation in treatment practices and outcomes are structured more broadly by multilevel processes related to communities, treatment programs, and characteristics of the patient, as well as their complex interplay.

DISCUSSION

Our findings will inform clinical decision making by patients and providers as well as public health responses to the rising number of young adults seeking treatment for OUD amidst the opioid and polysubstance overdose crisis in the U.S.

A retrospective analysis of the social determinants of health affecting stroke outcomes in a small hospital situated in a health professional shortage area (HPSA)

Where someone lives is a major determinant of population health. In the United States, people who live in Health Professional Shortage Areas are considered medically underserved and have a higher propensity for conditions such as stroke, hypertension, and diabetes. Our goal was to better understand the diverse needs of patients presenting to the Crouse Hospital emergency department with stroke symptoms. Crouse Hospital is a small community hospital located in a shortage area serving both urban and rural populations in and around Syracuse, New York. Despite its small size, Crouse Hospital quickly became a major comprehensive stroke center in Central New York. With this study we assessed the social factors affecting the stroke patient population in the community and compared these characteristics between those living in served and underserved areas. Informed by the social determinants of health framework, we analyzed 1731 incidents of stroke that occurred between January 2019 and January 2021, and observed that the circumstances associated with stroke varied by service category and race, with White patients and those from served areas having better stroke outcomes compared to those residing in underserved areas and those that were not White. Our analyses help us to understand the underlying factors influencing the observed disparities and allow us to move forward by implementing informed community-based interventions to decrease stroke incidence and improve post-stroke care. Using our example other small hospitals can enact similar strategies to address the social determinants affecting their patients to improve stroke outcomes in their region.

Neural and Psychosocial Mechanisms Underlying Alcohol Use and Pain Interactions: Overview of Current Evidence and Future Directions

Purpose of Review

A growing body of research indicates bidirectional associations between alcohol use and pain. In this review, we highlight common neural and psychosocial mechanisms underlying pain and alcohol use and identify current gaps in the literature regarding alcohol/pain interactions. We also suggest future directions for the field moving forward, including more nuanced conceptualization of alcohol's negative reinforcing effects in the context of pain, broader use of clinically-relevant experimental pain induction modalities, and characterization of age, biological sex, gender, race, and ethnicity as moderators of pain/alcohol interactions.

Recent Findings

Acute alcohol intake has analgesic and negative-reinforcing effects in the context of pain, and chronic heavy alcohol use appears to increase risk for development of chronic pain. At the same time, pain, both acute and chronic, acts as a proximal antecedent for alcohol use and is associated with relapse risk for individuals in recovery from alcohol use disorder.

Summary

Although the links between alcohol use and pain are increasingly appreciated, significant gaps in understanding remain and systematic study of alcohol/pain interactions at all levels, including basic, preclinical, translational, and interventional, is needed.

Estimates of Major Depressive Disorder and Treatment Among Adolescents by Race and Ethnicity

Importance

The COVID-19 pandemic has contributed to poorer mental health and a greater need for treatment. Nationally representative estimates of major depressive disorder (MDD) and mental health treatment among US adolescents during the pandemic are needed.

Objective

To estimate MDD prevalence among adolescents, evaluate mental health treatment use among adolescents with MDD, and assess differences by race and ethnicity.

Design, Setting, and Participants

This cross-sectional analysis of the nationally representative 2021 National Survey on Drug Use and Health included noninstitutionalized US adolescents between the ages of 12 and 17 years (n = 10 743). Analytic weights were applied to all rates and model estimates to be nationally representative and account for sample design and survey nonresponse. Data were collected from January 14 to December 20, 2021, and analyzed from February 11 to April 3, 2023.

Exposures

Self-reported race and ethnicity.

Main Outcomes and Measures

Dichotomous outcomes of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), MDD-specific mental health treatment, any type of mental health treatment, telehealth visits, and delays in mental health treatment.

Results

The sample included 10 743 adolescents (51.1% male). Self-reported race and ethnicity included 5.1% Asian, 14.1% Black, 23.3% Latinx, 51.2% White, and 6.3% more than 1 race. Ages were evenly distributed: 34.0% aged 12 to 13 years; 33.3% aged 14 to 15 years; and 32.7% aged 16 to 17 years. Adolescents of more than 1 race or ethnicity had the highest MDD rate (26.5%). Compared with White adolescents, the lowest rates of any MDD treatment overall were found among Latinx adolescents (29.2% [95% CI, 22.2%-36.2%]) and those of more than 1 race or ethnicity (21.1% [95% CI, 11.6%-30.7%]). Similar results were found for treatment by any clinician (Latinx, 25.6% [95% CI, 18.8%-32.4%]; >1 race or ethnicity, 19.1% [95% CI, 9.7%-28.6%]), treatment by a mental health specialist (Latinx, 22.9% [95% CI, 16.9%-28.9%]; >1 race or ethnicity, 16.7% [95% CI, 7.1%-26.3%]), treatment by a nonspecialist clinician (Latinx, 7.3% [95% CI, 3.3%-11.3%]; >1 race or ethnicity, 4.8% [95% CI, 1.9%-7.7%]), and use of any psychotropic medication prescription (Latinx, 11.6% [95% CI, 7.3%-15.9%]; >1 race or ethnicity, 8.3% [95% CI, 2.8%-13.7]). Compared with White adolescents, Black adolescents had lower rates of MDD treatment by any clinician (31.7% [95% CI, 23.7%-39.8%]) and by nonspecialist clinicians (8.4% [95% CI, 3.8%-13.2%]) and experienced lower prescription rates for any psychotropic medication (12.6 [95% CI, 4.6%-20.6%]). Asian (16.0% [95% CI, 5.0%-27.2%]) and Latinx (17.8% [95% CI, 12.6%-23.0%]) adolescents had lower rates of virtual mental health treatment compared with White adolescents. Black (19.1% [95% CI, 14.1%-24.2%]) and Latinx (17.9% [95% CI, 15.0%-21.1%]) adolescents had lower rates of appointments transition to telehealth, while Black adolescents (14.1% [95% CI, 10.7%-17.4%]) experienced delays getting their prescriptions.

Conclusions and Relevance

During the first full calendar year of the pandemic, approximately 1 in 5 adolescents had MDD, and less than half of adolescents who needed treatment had any mental health treatment. Adolescents in racial and ethnic minority groups, particularly Latinx, experienced the lowest treatment rates. Federal policy should target adolescents as a whole, and minority populations in particular, to ensure equitable treatment access. Efforts should consider the social, racial, ethnic, and cultural determinants of health.

Choice of high-deductible health plans among enrollees with a substance use disorder

INTRODUCTION

High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP.

METHODS

Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level.

RESULTS

The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling.

CONCLUSION

Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

Population-based examination of substance use disorders and treatment use among US young adults in the National Survey on Drug Use and Health, 2011-2019

Background

Compared with adults of other age groups, young adults are more likely to have substance use disorders (SUDs) but less likely to receive treatment. Untreated SUDs can lead to lethal consequences, particularly deaths related to drug overdose.

Objectives

This study aimed to examine trends and sociodemographic differences in the prevalence and treatment use of SUDs among US young adults aged 18 to 25 in the National Survey on Drug Use and Health 2011-2019.

Methods

Bivariable logistic regression analyses were conducted to examine annual changes in the prevalence and treatment use of SUDs, and multivariable logistic regression was used to examine sociodemographic differences in SUD prevalence and treatment use in the pooled sample of young adults from 2011 to 2019.

Results

From 2011 to 2019, the overall SUD prevalence increased significantly from 5.4% to 6.2%. Cannabis use disorder was the most common SUD annually. Groups with lower prevalence of SUDs included females, young adults aged 22-25, and Hispanic, Black, and Asian participants. Across the survey years, the prevalence of treatment use fluctuated insignificantly between 10.9% and 16.9% among young adults with SUDs, and most young adults received SUD treatment in self-help groups and residential and outpatient rehabilitation facilities. Compared to White participants, treatment use was lower in Hispanic, Black, Asian participants, as well as young adults of two or more races. Young adults covered by Medicaid/CHIP were more likely to use treatment.

Conclusions

This study revealed an alarming level of unmet treatment need and significant disparities in treatment use among young adults with SUDs. To reduce barriers to treatment utilization, more coordinated efforts that leverage policy and structural changes alongside innovations to engage young adults with SUD care are needed.

Differential risks of syringe service program participants in Central Ohio: a latent class analysis

BACKGROUND

Significant heterogeneity exists among people who use drugs (PWUD). We identify distinct profiles of syringe service program (SSP) clients to (a) evaluate differential risk factors across subgroups and (b) inform harm reduction programming.

METHODS

Latent class analysis (LCA) was applied to identify subgroups of participants (N = 3418) in a SSP in Columbus, Ohio, from 2019 to 2021. Demographics (age, sex, race/ethnicity, sexual orientation, housing status) and drug use characteristics (substance[s] used, syringe gauge, needle length, using alone, mixing drugs, sharing supplies, reducing use, self-reported perceptions on the impact of use, and treatment/support resources) were used as indicators to define latent classes. A five-class LCA model was developed, and logistic regression was then employed to compare risk factors at program initiation and at follow-up visits between latent classes.

RESULTS

Five latent classes were identified: (1) heterosexual males using opioids/stimulants with housing instability and limited resources for treatment/support (16.1%), (2) heterosexual individuals using opioids with stable housing and resources for treatment/support (33.1%), (3) individuals using methamphetamine (12.4%), (4) young white individuals using opioids/methamphetamine (20.5%), and (5) females using opioids/cocaine (17.9%). Class 2 served as the reference group for logistic regression models, and at the time of entry, class 1 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs, with persistently higher odds of sharing supplies and mixing drugs at follow-up. Class 3 was more likely to report history of overdose, sharing supplies, and mixing drugs, but outcomes at follow-up were comparable. Class 4 was the least likely to report history of overdose, HCV, and mixing drugs, but the most likely to report HIV. Class 5 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs at entry, and higher reports of accessing substance use treatment and testing positive for HCV persisted at follow-up.

CONCLUSIONS

Considerable heterogeneity exists among PWUD, leading to differential risk factors that may persist throughout engagement in harm reduction services. LCA can identify distinct profiles of PWUD accessing services to tailor interventions that address risks, improve outcomes, and mitigate disparities.

Improving assessment of alcohol treatment barriers among Latino and White adults with an alcohol use disorder: Development of the barriers to specialty alcohol treatment scale

INTRODUCTION

The present study's aims were two-fold. First, we sought to validate a novel measure to assess barriers to specialty alcohol treatment among White and Latino individuals with an alcohol use disorder (AUD): The Barriers to Specialty Alcohol Treatment (BSAT) scale. Second, we sought to demonstrate that the BSAT scale could be used to explain Latino-White disparities in barriers to alcohol treatment.

METHODS

In 2021, we recruited an online national sample of 1200 White and Latino adults with a recent AUD. Participants completed an online questionnaire that included the BSAT items. Confirmatory and exploratory factor analyses were conducted to validate the BSAT. Multiple group analyses across race/ethnicity and language were also performed using the final model.

RESULTS

The final model consisted of 36 items across 7 factors that reflect barriers related to low problem recognition, recovery goals, low perceived treatment efficacy, cultural factors, immigration-related concerns, low perceived social support, and logistical barriers. The final model's factor structure and factor loadings held up across race/ethnicity and language. The top endorsed barriers were low problem recognition, recovery goals, low perceived social support, logistical issues, and low perceived treatment efficacy. Compared to Whites, Latinos were more likely to report perceived lack of social support, logistical barriers, low perceived treatment efficacy, cultural barriers, and immigration-related concerns as barriers.

CONCLUSION

Findings provide empirical support for the validity of the BSAT scale, which offers improved measurement of specialty alcohol treatment barriers and can be used to explore Latino-White disparities in a future study.

Sexual minorities and substance use treatment utilization: New evidence from a national sample

INTRODUCTION

Minority stress theory suggests that sexual minorities would be, on average, less likely than heterosexual individuals to seek out substance use treatment (due to concerns of stigma and rejection). However, prior research on the subject is mixed, and largely dated. In light of historic increases in societal acceptance and legal protections for sexual minorities, the field needs an up-to-date assessment of treatment utilization among this population.

METHODS

This study used data from the 2015-2019 National Survey on Drug Use and Health to examine the association between key independent variables (sexual identity, gender) and substance use treatment utilization using binary logistic regression. We conducted analyses using a sample of adults with a past-year substance use disorder (N = 21,926).

RESULTS

Controlling for demographic factors, with heterosexual individuals as the comparison group, gay/lesbian individuals (AOR = 2.12, CI = 1.19-3.77) were significantly more likely and bisexual individuals (AOR = 0.49, CI = 0.24-1.00) significantly less likely to report treatment utilization. Bisexual individuals were also less likely than gay/lesbian individuals to report treatment utilization (AOR = 0.10, CI = 0.05-0.23). Interaction tests examining sexual orientation and gender showed no difference in treatment utilization between gay men and lesbian women, and revealed that bisexual identity was associated with decreased likelihood of treatment utilization for men (p = .004) but not for women.

CONCLUSION

Sexual orientation, particularly in the context of social identity, plays a significant role in substance use treatment utilization. Bisexual men face unique barriers to treatment, which is concerning given the high rates of substance use among this and other sexual minority populations.

Gender and ethnic disparities in students' perceptions of how different groups of persons suspected of possessing and/or selling illegal drugs are treated in the criminal justice system

Ethnic minorities and individuals of low socioeconomics status are disproportionately more likely to be detained, arrested, and convicted and receive longer sentences for drug offenses. This article explores gender and ethnic differentials among college students' perceptions on the criminal justice treatment of different gender, ethnic, and income groups applied to alleged drug offenders. It uses survey data provided by students at a large public university in South Florida. A two-way classification model examines the nature of disparities in perceptions. Students perceive widespread ethnic inequalities and female and Black students perceive greater disparities in the criminal justice system for all disadvantaged groups.

Outpatient substance abuse treatment completion rates for racial-ethnic minorities during the Great Recession

There has been minimal research linking the effects on racial-ethnic minorities' health outcomes, particularly research focused on racial-ethnic minorities seeking outpatient substance abuse treatment in the United States. The Great Recession from December 2007 to June 2009 in the United States provides the backdrop against the completion of substance abuse treatments among racial-ethnic minorities that may be associated with the impacts on users' social realities. We utilized data from the 2006-2011 Treatment Episode Datasets-Discharge (TEDS-D) dataset which collects data on outpatient substance abuse treatment institutions throughout the United States. The substance abuse treatment completion rates were higher prior to the Great Recession and lower following the Great Recession. Hispanics were more likely than non-Hispanic whites to complete substance abuse treatment, while other minority groups such as Non-Hispanic Blacks, were less likely to do so. Clients in the Northeast and West regions were more likely to successfully complete substance abuse treatment than those in the South. These findings have implications for impacting outpatient substance abuse treatment completion rates following the Great Recession to reduce racial-ethnic disparities which were impacted by region. Even amid an economic recession, treatment for substance abuse should continue to be a top concern.

Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center

INTRODUCTION

Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel.

METHODS

To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses.

RESULTS

Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment.

CONCLUSIONS

Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.

Association between pharmacologic treatment and hospital utilization at birth among neonatal opioid withdrawal syndrome mother-infant dyads

OBJECTIVE

We linked mother-baby dyads to explore associations between maternal medication-assisted therapy (MAT) and infants' pharmacologic treatment on birth hospital utilization for infants with NOWS.

METHODS

We extracted singleton infant and maternal delivery discharges from PHIS hospitals with large volumes of deliveries for 2016-2019. We matched newborns with NOWS to maternal delivery discharges by hospital, day of birth, mode of delivery, and ZIP code. We examined the association between maternal MAT, infants' pharmacologic treatment, and hospital utilization at birth.

RESULTS

We included N = 146 mother-baby dyads from six hospitals (74% match rate). Among matched dyads, 51% received maternal MAT, 60% pharmacotherapy (37% both). Infants treated non-pharmacologically and born to mothers receiving MAT had the shortest stays vs. infants without pharmacotherapy or MAT (RR = 0.29; 95% CI: 0.25-0.35).

CONCLUSIONS

These findings underscore the importance of adequate perinatal treatment for opioid use disorder to improve outcomes for mothers and infants with opioid exposure.

Sociodemographic differences in quality of treatment to Medicaid enrollees receiving buprenorphine

Background: Buprenorphine is a key medication to treat opioid use disorder, but little is known about how treatment quality varies across sociodemographic groups. Objective: We examined measures of treatment quality and explored variation by sociodemographic factors. Methods: We used Medicaid MAX data from 50 states from 2006 to 2014 to identify buprenorphine treatment episodes (N = 317,494). We used multivariable logistic regression to examine the quality of buprenorphine treatment along four dimensions: (1) sufficient duration, (2) effective dosage, and concurrent prescribing of (3) opioid analgesics and (4) benzodiazepines. We explored how quality varied by race/ethnicity, age, sex, and urbanicity. Results: In adjusted models, compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic individuals had lower odds of receiving effective dosage (aORs = 0.79 and 0.89, respectively) and sufficient duration (aORs = 0.64 and 0.71, respectively), and lower odds of concurrent prescribing of opioid analgesics (aORs = 0.86 and 0.85, respectively) and benzodiazepines (aORs = 0.51 and 0.59, respectively). Older individuals had higher odds of sufficient duration (aORs from 1.21-1.33), but also had higher odds of concurrent opioid analgesics prescribing (aORs from 1.29-1.56) and benzodiazepines (aORs from 1.44-1.99). Females had higher odds of sufficient duration (aOR = 1.12), but lower odds of effective dosage (aOR = 0.77) and higher odds of concurrent prescribing of opioid analgesics (aOR = 1.25) and benzodiazepines (aOR = 1.16). Compared to individuals living in metropolitan areas, individuals living in non-metropolitan areas had higher odds of sufficient duration (aORs = 1.11 and 1.24) and effective dosage (aORs = 1.06 and 1.33), and lower odds of concurrent prescribing (aORs from 0.81-0.98). Conclusions: Black and Hispanic individuals were less likely to receive effective buprenorphine dosage and sufficient duration. Quality results were mixed for older and female individuals; although these individuals were more likely to receive treatment of sufficient duration, they were also more likely to be concurrently prescribed potentially contraindicated medications, and females were less likely to receive effective dosage. Findings raise concerns about adequacy of care for minority and other at-risk populations.

Racial-ethnic disparities across substance use disorder treatment settings: Sources of treatment insurance, socioeconomic correlates and clinical features

Aim: Contrary to expectations, studies of racial-ethnic disparities in substance use disorder (SUD) treatment frequently uncover minority-majority parity in access and utilization of services. What accounts for the anomaly? To answer the question, this study explores racial-ethnic differences in the odds of utilization of SUD treatment in varied settings (e.g., the criminal justice system, private doctor's office, etc.), adjusting for sources of treatment insurance, socioeconomic correlates of treatment (e.g., employment, income, education), as well as clients' clinical features (e.g., type of substance abuse/dependence, co-morbidities, health status). Methods: Data were compiled from the National Survey of Drug Use and Health (NSDUH) dataset, 2002-2014. The sample consisted of respondents with a past year diagnosis of a substance use disorder, who also reported having received treatment (n = 6,207). Data were pooled to maximize subgroup analyses. Weight- and design- adjusted logistic regressions were use to analyze factors predicting SUD treatment source. Results: Blacks were more likely than Whites to receive treatment through the criminal justice system and Whites more likely than Blacks and Latinx to receive treatment at a doctor's office. Blacks were also more likely than Whites to receive treatment through inpatient/outpatient rehabilitation, before adjustments but not afterwards. Discussion: In this study we show that even after adjusting for mechanisms expected to shape pathways from race-ethnicity to SUD treatment sites, significant racial-ethnic disparities persist. This fills an important gap in the literature in that disparities research has not explicitly modeled racial-ethnic variation across the full range of SUD treatment sites.

Experiences with and impacts of the COVID-19 pandemic by substance use disorder in the early phase of pandemic in the United States: A cross-sectional survey, 2020

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic could disproportionately affect individuals who have a substance use disorder (SUD). However, little information exists on COVID-19-related experiences among individuals with a SUD. We examined whether individuals with a SUD differ from other individuals with regard to COVID-19 testing, susceptibility, and employment-related vulnerability.

METHODS

We used data from a U.S. nationally representative survey (n = 1,208). Using logistic regressions, we examined whether individuals with SUDs differ from other individuals regarding underlying health conditions, COVID-19 testing, access to paid sick leave, and loss of employment. Data were collected in late May-early June, 2020.

RESULTS

Four percent of participants reported that a healthcare professional had told them they had a SUD. We found that, compared to those without SUDs, respondents with SUDs had higher odds of having lost their job due to the pandemic (adjusted odds ratio [AOR]:5.17, 95% confidence interval [CI]:2.28-11.74). Among individuals who were employed prior to the pandemic, people with SUDs had lower odds of having paid sick leave (AOR:0.26, 95% CI:0.09-0.74).

CONCLUSION

Our study indicates that individuals with SUDs could be disproportionately affected by COVID-19 economically, which might worsen SUD and racial/ethnic health disparities.

Racial/Ethnic disparities in drug use during the COVID 19 pandemic: Moderating effects of non-profit substance use disorder service expenditures

The COVID-19 pandemic influenced individuals’ anxiety and depression across the United States over a short period, and some Americans relied on drugs for coping. This study examines American adults’ drug use trajectories in response to changing anxiety and depression levels during the COVID-19 pandemic and the moderating role of substance use disorder (SUD) services provided by non-profit facilities in anxiety/depression-induced drug use. Heterogeneity in such relationships is further explored based on race/ethnicity. This study used a nationally representative sample of 1,176 American adults who reported drug use between May 1, 2020, and June 30, 2021. Using individual-fixed effects Poisson estimators, the current study empirically modeled drug use changes according to changing anxiety/depression levels. Interaction terms between anxiety/depression levels and per capita spending by non-profit SUD facilities were used to explore the moderating effect of SUD service expenditures. Racial/ethnic disparities were explored in subgroup analyses on non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian samples. We found more frequent drug use in response to elevated anxiety and depression during the COVID-19 pandemic. Greater spending on SUD service by non-profit facilities at the county level was associated with reduced drug consumption associated with anxiety and depression, with greater benefits for racial/ethnic minorities. Findings provide important policy implications for distributing public funds for non-profit SUD facilities for mitigating SUD risks, especially among racial/ethnic minorities.

Substance use related violent deaths among racial/ethnic groups in the United States

While prior research highlights the overlap of substance use and violent death, few examine this overlap among different racial/ethnic groups or how patterns change over time. This study examines how substance use related deaths differ by racial/ethnic groups in the United States. We use data from the National Violent Death Reporting System (NVDRS), which includes violent deaths from 43 states in the U.S., collected for the decade between 2009 and 2019 (N = 226,459). Fixed-effects multivariate models examined whether race/ethnicity was associated with substance use-related death over time, controlling for additional demographic and clinical factors. Results showed a significantly larger rate of increase over time for African American and Hispanic (any race) persons compared to White non-Hispanic persons for most types of substance use-related deaths. While current rates of substance use may show little variability between African American, Hispanic, and White non-Hispanic individuals, this research suggests that the consequences for substance use, including death, may be disproportional.

Access to Mental Healthcare in the 21st Century: An Evolutionary Concept Analysis

BACKGROUND

One of the most important aspects of receiving medical care is access to that care. For people with mental illness who have greater healthcare needs and are at risk for poor health outcomes, reduced access to care constitutes a crisis. While the COVID-19 (coronavirus disease 2019) pandemic continues to affect the United States, specifying what it means to have access to mental healthcare is more critical than ever.

AIMS

The aims of this concept analysis are to review definitions and descriptions of access to mental healthcare in the literature and to synthesize the relevance of these findings to inform future research, theory development, policy, and practice.

METHODS

The concept of access to mental healthcare was analyzed using Rodgers's evolutionary concept analysis method. CINAHL, PsycINFO, and MEDLINE were queried for peer-reviewed articles about access to mental healthcare published from January 2010 to April 2020 (n = 72). Data were reviewed for concept antecedents, attributes, consequences, surrogate, and related terms.

RESULTS

Five models of access to mental healthcare were identified, with several antecedents and consequences: utilization, economic loss/gain, incarceration, and patient/provider satisfaction. Cross-sectional and predictive studies highlighted three interrelated attributes: clinical management, healthcare delivery, and connectedness.

CONCLUSIONS

The concept of access to mental healthcare is often used stagnantly across disciplines to create health policies, yet the concept is transformative. Future research requires up-to-date operational definitions of access to mental healthcare to target interdisciplinary approaches.

Use of Medication for Opioid Use Disorder Among US Adolescents and Adults With Need for Opioid Treatment, 2019

Importance

Medication for opioid use disorder (MOUD) is the criterion standard treatment for opioid use disorder (OUD), but nationally representative studies of MOUD use in the US are lacking.

Objective

To estimate MOUD use rates and identify associations between MOUD and individual characteristics among people who may have needed treatment for OUD.

Design, Setting, and Participants

Cross-sectional, nationally representative study using the 2019 National Survey on Drug Use and Health in the US. Participants included community-based, noninstitutionalized adolescent and adult respondents identified as individuals who may benefit from MOUD, defined as (1) meeting criteria for a past-year OUD, (2) reporting past-year MOUD use, or (3) receiving past-year specialty treatment for opioid use in the last or current treatment episode.

Main Outcomes and Measures

The main outcomes were treatment with MOUD compared with non-MOUD services and no treatment. Associations with sociodemographic characteristics (eg, age, race and ethnicity, sex, income, and urbanicity); substance use disorders; and past-year health care or criminal legal system contacts were analyzed. Multinomial logistic regression was used to compare characteristics of people receiving MOUD with those receiving non-MOUD services or no treatment. Models accounted for predisposing, enabling, and need characteristics.

Results

In the weighted sample of 2 206 169 people who may have needed OUD treatment (55.5% male; 8.0% Hispanic; 9.9% non-Hispanic Black; 74.6% non-Hispanic White; and 7.5% categorized as non-Hispanic other, with other including 2.7% Asian, 0.9% Native American or Alaska Native, 0.2% Native Hawaiian or Pacific Islander, and 3.8% multiracial), 55.1% were aged 35 years or older, 53.7% were publicly insured, 52.2% lived in a large metropolitan area, 56.8% had past-year prescription OUD, and 80.0% had 1 or more co-occurring substance use disorders (percentages are weighted). Only 27.8% of people needing OUD treatment received MOUD in the past year. Notably, no adolescents (aged 12-17 years) and only 13.2% of adults 50 years and older reported past-year MOUD use. Among adults, the likelihood of past-year MOUD receipt vs no treatment was lower for people aged 50 years and older vs 18 to 25 years (adjusted relative risk ratio [aRRR], 0.14; 95% CI, 0.05-0.41) or with middle or higher income (eg, $50 000-$74 999 vs $0-$19 999; aRRR, 0.18; 95% CI, 0.07-0.44). Compared with receiving non-MOUD services, receipt of MOUD was more likely among adults with at least some college (vs high school or less; aRRR, 2.94; 95% CI, 1.33-6.51) and less likely in small metropolitan areas (vs large metropolitan areas, aRRR, 0.41; 95% CI, 0.19-0.93). While contacts with the health care system (85.0%) and criminal legal system (60.5%) were common, most people encountering these systems did not report receiving MOUD (29.5% and 39.1%, respectively).

Conclusions and Relevance

In this cross-sectional study, MOUD uptake was low among people who could have benefited from treatment, especially adolescents and older adults. The high prevalence of health care and criminal legal system contacts suggests that there are critical gaps in care delivery or linkage and that cross-system integrated interventions are warranted.

Evaluating culturally and linguistically integrated care for Latinx adults with mental and substance use disorders

Objective: To evaluate changes in health and health care utilization outcomes for Latinx adults with substance use and mental disorders receiving integrated behavioral and primary health care.Design: Study sample included enrollees who completed baseline, 6-month and 12-month assessments (n = 107). Study outcomes were depression symptom severity, anxiety symptom severity, illicit drug use, emergency department utilization and homelessness status. Pre-post analyses were conducted using paired t-test and McNemar test to examine changes in study outcomes. Multivariable regression model estimated through generalized estimating equations explored the influence of the intervention on study outcomes. Results were presented in adjusted odds ratios (AOR) and 95% confidence intervals (CI).Results: Participants were less likely to report depressive symptoms (AOR: 0.496, 95%CI: 0.296-0.832), less likely to report anxiety symptoms (AOR: 0.539, 95%CI: 0.329-0.884), and less likely to experience homelessness (AOR: 0.556, 95%CI: 0.328-0.943) at 6-month assessment compared to baseline. Participants were also less likely to report depressive symptoms (AOR: 0.378, 95%CI: 0.209-0.684), less likely to report anxiety symptoms (AOR: 0.471, 95%CI: 0.270-0.821), less likely to experience homelessness (AOR: 0.333, 95%CI: 0.189-0.587), and less likely to utilize the emergency department in the past 30 days (AOR: 0.397, 95%CI: 0.188-0.837) at 12-month assessment compared to baseline.Conclusions: Integrating culturally responsive behavioral and primary health care services is critical for addressing the needs of Latinx adults with mental and substance use disorders, and other chronic diseases. This initiative has the potential to reduce disparities in access to and engagement in care for Latinx adults.

Black-White differences in barriers to specialty alcohol and drug treatment: findings from a qualitative study

The objective of this study was to explore, in-depth, differences in barriers to specialty alcohol and drug treatment services between Black and White participants with recent substance use disorders (SUD). We recruited 34 participants with a recent SUD of White and Black racial/ethnic descent for qualitative interviews. Interviews were coded to identify barriers to specialty treatment. We found that barriers related to stigma and lack of social support were more pervasive in the narratives of Blacks as compared to Whites. Results suggest that stigma and lack of perceived social support may impact Blacks more than Whites in seeking SUD treatment.

Patterns of enrollment in a New Orleans women's substance use rehabilitation center

BACKGROUND

Research has told us little about the demographics of individuals entering substance use programs in New Orleans, Louisiana, especially women accessing treatment programs. Considering that New Orleans is a predominantly Black city and both substance use treatment and research have historically left out Black patients, this study evaluates the age, race, insurance status, education level, and substance of choice for patients entering Grace House Rehabilitation Center, an all women nonprofit substance use treatment program in New Orleans, Louisiana.

METHODS

Since 2013, Tulane School of Medicine students have held weekly primary care clinics at Grace House. This study used the clinic's patients' handwritten intake forms to collect demographic variables between 2013 and 2019. The study then evaluated the data using descriptive statistical analysis.

RESULTS

The study analyzed 743 patient charts. We found that 78.4% of women admitted to Grace House were white (n = 627), and 14.5% of women were Black (n = 1160). The study excluded all other racial and ethnic groups due to the groups' small sample size. The average age at admittance was 34.7 years for both white and Black women; however, the average age for Black women was 42 years old. The 743 women studied reported the use of 1123 unique substances. While more than half of both populations used only one type of substance, Black women more commonly used only one substance.

CONCLUSION

New Orleans is a predominantly Black community, yet young Black women are largely missing from the patient population that we studied. While multiple reasons exist for the lack of Black women in this population, Black substance-using women are clearly left out of the life-saving treatment that they deserve. The medical community must investigate further to make genuine, impactful changes to how substance use treatment is accessed by all minority groups, but especially Black women.

Treatment of substance use disorders among black and white adults: rates, correlates, and racial discrimination

BACKGROUND

Racial disparities in access to psychiatric treatment are well documented, but less is known about disparities in use of substance use disorder (SUD) treatment.

OBJECTIVES

To compare Black and White individuals with SUDs on overall differences and correlates of SUD treatment receipt.

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), we compared Black (n = 1,312 unweighted) and White (n = 3,076 unweighted) adults with past-year SUDs on proportions who received SUD treatment and on sociodemographic and clinical correlates of receiving treatment. Due to large samples, effect sizes, rather than p-values, were used to identify substantial differences between racial groups. Multivariate analyses were used to identify independent differentiating factors.

RESULTS

Black individuals with past-year SUDs were no less likely to receive treatment than White individuals (10.1% versus 11.3%; p = 0.24). Bivariate analyses demonstrated similar correlates of treatment receipt between racial groups, including sociodemographic disadvantage, racial discrimination, criminal justice involvement, low social support, multimorbidity of SUDs and psychiatric disorders, and prior SUD treatment. Multivariate analyses demonstrated that low income, unemployment, and criminal justice involvement had a significantly stronger association with receiving treatment for Whites, while parental problems with alcohol was more strongly associated with treatment among Black individuals (p < 0.05).

CONCLUSION

Recognizing methodological limitations, our findings are encouraging suggesting that Black individuals with SUDs are not less likely than White individuals to receive treatment and have few differences in correlates of receiving treatment. However, treatment receipt was low for both groups and remains a major unmet challenge.

Using machine learning to advance disparities research: Subgroup analyses of access to opioid treatment

Objective

To operationalize an intersectionality framework using a novel statistical approach and with these efforts, improve the estimation of disparities in access (i.e., wait time to treatment entry) to opioid use disorder (OUD) treatment beyond race.

Data source

Sample of 941,286 treatment episodes collected in 2015–2017 in the United States from the Treatment Episodes Data Survey (TEDS‐A) and a subset from California (n = 188,637) and Maryland (n = 184,276), states with the largest sample of episodes.

Study design

This retrospective subgroup analysis used a two‐step approach called virtual twins. In Step 1, we trained a classification model that gives the probability of waiting (1 day or more). In Step 2, we identified subgroups with a higher probability of differences due to race. We tested three classification models for Step 1 and identified the model with the best estimation.

Data collection

Client data were collected by states during personal interviews at admission and discharge.

Principal findings

Random forest was the most accurate model for the first step of subgroup analysis. We found large variation across states in racial disparities. Stratified analysis of two states with the largest samples showed critical factors that augmented disparities beyond race. In California, factors such as service setting, referral source, and homelessness defined the subgroup most vulnerable to racial disparities. In Maryland, service setting, prior episodes, receipt of medication‐assisted opioid treatment, and primary drug use frequency augmented disparities beyond race. The identified subgroups had significantly larger racial disparities.

Conclusions

The methodology used in this study enabled a nuanced understanding of the complexities in disparities research. We found state and service factors that intersected with race and augmented disparities in wait time. Findings can help decision makers target modifiable factors that make subgroups vulnerable to waiting longer to enter treatment.

Documenting Behavioral Health Needs in an Urban Setting

Most local communities lack the capacity to conduct behavioral health needs assessments. The purpose of this paper is to describe a mixed-methods approach to estimate the behavioral health needs in St. Louis, MO. Data were drawn from multiple sources including local and state government prevalence estimates, medical records, and key informant interviews. The most prevalent behavioral conditions were depression, alcohol, and drug abuse. Priority populations were residents with co-occurring disorders, youth transitioning into the adult behavioral system, and homeless individuals with behavioral health needs. Treatment rates for behavioral health conditions were low, relative to identified needs. There are significant provider shortages and high staff turnover, which extend wait times, diminish the quality of care, and contribute to the use of emergency departments for behavioral health care. The data and methods described in this paper could be helpful to other municipalities that are looking to conduct behavioral health needs assessments.

Receipt of evidence-based alcohol-related care in a national sample of transgender patients with unhealthy alcohol use: Overall and relative to non-transgender patients

BACKGROUND/OBJECTIVE

Evidence-based alcohol-related care-brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)-should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use.

METHODS

We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0-14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0-365 days following screening), and filled prescriptions for medications to treat AUD (documented 0-365 days following screening) for transgender patients, and compared to that of non-transgender patients.

RESULTS

Among transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2-78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7-17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1-20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98-1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12-1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06-1.28, p = 0.002).

CONCLUSIONS

Findings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall.

How is the COVID-19 pandemic shaping transportation access to health care?

The Coronavirus disease 19 (COVID-19) pandemic has disrupted both transportation and health systems. While about 40% of Americans have delayed seeking medical care during the pandemic, it remains unclear to what extent transportation is contributing to missed care. To understand the relationship between transportation and unmet health care needs during the pandemic, this paper synthesizes existing knowledge on transportation patterns and barriers across five types of health care needs. While the literature is limited by the absence of detailed data for trips to health care, key themes emerged across populations and settings. We find that some patients, many of whom already experience transportation disadvantage, likely need extra support during the pandemic to overcome new travel barriers related to changes in public transit or the inability to rely on others for rides. Telemedicine is working as a partial substitute for some visits but cannot fulfill all health care needs, especially for vulnerable groups. Structural inequality during the pandemic has likely compounded health care access barriers for low-income individuals and people of color, who face not only disproportionate health risks, but also greater difficulty in transportation access and heightened economic hardship due to COVID-19. Partnerships between health and transportation systems hold promise for jointly addressing disparities in health- and transportation-related challenges but are largely limited to Medicaid-enrolled patients. Our findings suggest that transportation and health care providers should look for additional strategies to ensure that transportation access is not a reason for delayed medical care during and after the COVID-19 pandemic.

Utilization of substance use treatment among criminal justice-involved individuals in the United States

Over six million individuals are involved with the criminal justice system in the United States, of which a large proportion report extensive substance use. We examined the extent to which criminal justice-involvement affects substance use treatment utilization among participants from one of the largest annual surveys on substance use in the U.S., the National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression analyses indicated that criminal justice involvement was significantly associated with receiving substance use treatment in the past year (AOR 8.00, 95% CI: 6.23-10.27, p < 0.001). However, those with criminal justice histories continue to face barriers to treatment. Among individuals ages 12 and older who reported past year criminal justice involvement and met criteria for a substance use disorder, 18.9% reported receiving past year substance use treatment. After controlling for key demographic and drug use characteristics in a multivariable logistic regression model, Black criminal justice involved Americans were somewhat less likely to report receiving substance use treatment in the past year compared to White criminal justice involved Americans, although the association was not significant (AOR 0.87, 95% CI 0.58-1.29, p = 0.481). Treatment programs targeted to increase minority engagement and address persistent barriers to substance use treatment may be valuable for curbing substance use and recidivism among criminal justice-involved individuals.

Implementation of office-based buprenorphine treatment for opioid use disorder

BACKGROUND

Buprenorphine-based medication-assisted treatment (B-MAT) is a powerful, concrete intervention that can be provided by nurse practitioners (NPs) to reduce opioid-related overdoses in patients with opioid use disorder (OUD). However, multiple barriers exist to provide and access this therapy.

LOCAL PROBLEM

A rural Midwestern county struggled with increasing OUD and scant access to B-MAT. A nurse-led, community clinic had the potential to expand access to treatment but no support structure to provide it.

METHODS

In this quality improvement project, a one-group posttest-only design was used to assess treatment access, care quality, and patient characteristics.

INTERVENTIONS

An evidence-based, nurse led weekly B-MAT clinic using a low-threshold, chronic-care model for treatment of OUD.

RESULTS

The B-MAT clinic expanded county-wide access by 34% over seven months. A total of 23 patients were seen with 21 eligible for treatment with B-MAT. All nine patients with at least 90-day continuous treatment were retained in the program. Three quarters of patients had at least 30 days of active buprenorphine-naloxone coverage and 17% of all patients were lost to follow up. There were no induction-related adverse events, no fatalities, and one nonfatal overdose. In a chart review, 85% of patients met at least six of eight quality criteria.

CONCLUSIONS

This low-barrier approach to OUD expanded access to treatment and demonstrated a model stable enough to continue delivering care throughout the first 5 months of the novel coronavirus (COVID-19) pandemic. NPs in primary care settings can effectively provide B-MAT in a low-threshold, office-based setting.

Racial/Ethnic Disparities in Mutual Help Group Participation for Substance Use Problems

Mutual help groups are a ubiquitous component of the substance abuse treatment system in the United States, showing demonstrated effectiveness as a treatment adjunct; so, it is paramount to understand whether they are as appealing to, and as effective for, racial or ethnic minority groups as they are for Whites. Nonetheless, no known comprehensive reviews have examined whether there are racial/ethnic disparities in mutual help group participation. Accordingly, this study comprehensively reviewed the U.S. literature on racial/ethnic disparities in mutual help participation among adults and adolescents with substance use disorder treatment need. The study identified 19 articles comparing mutual help participation across specific racial/ethnic minority groups and Whites, including eight national epidemiological studies and 11 treatment/community studies. Most compared Latinx and/or Black adults to White adults, and all but two analyzed 12-step participation, with others examining "self-help" attendance. Across studies, racial/ethnic comparisons yielded mostly null (N = 17) and mixed (N = 9) effects, though some findings were consistent with a racial/ethnic disparity (N = 6) or minority advantage (N = 3). Findings were weakly suggestive of disparities for Latinx populations (especially immigrants, women, and adolescents) as well as for Black women and adolescents. Overall, data were sparse, inconsistent, and dated, highlighting the need for additional studies in this area.

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16-24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015-2018 was used to summarize service use among 13,363 transition age youth age 16-24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity

OBJECTIVE

To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.

DATA SOURCES

Five percent random sample of Medicare claims from 2009 to 2016.

STUDY DESIGN

We compared Medicare beneficiaries in MSSP ACOs to non-MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference-in-difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference-in-difference-in-differences (DDD) design.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: -0.012, P < .001) and substance use (Coeff: -0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability- and age-eligible populations (Coeff: -0.028, P < .001; Coeff: -0.012, P < .001, respectively). MSSP ACO's were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability- and age-eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:-0.004, P < .001, and Coeff:-0.0002, P < .01 for disability- and age-eligible populations, respectively) and substance use-related stays for disability-eligible populations (Coeff:-0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.

CONCLUSIONS

We found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population-based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.

Where is the Family in Young Adult Substance Use Treatment? The Case for Systemic Family Therapy for Young Adults with Substance Use Disorders

Despite the prevalence of SUDs, many individuals remain untreated (Grant et al., JAMA Psychiatry, 73(1), 39-45, 2016). Substance use disorders (SUDs) in young adults present unique challenges and stressors to parents of these individuals (D’Aniello et al., American Journal of Family Therapy, 2020; Kaur et al., International Journal of Community Medicine and Public Health, 5(6), 2380-2383, 2018; Shumway et al., Alcoholism Treatment Quarterly, 37(1), 75-98, 2019). Parents and caregivers often facilitate their children’s care and provide pragmatic and emotional support to their children; this high level of care is challenging to maintain, as with any chronic, relapsing condition. In the case of SUDs, the challenges caregivers face may be exacerbated by the stigma and the blame associated with parents in the development and maintenance of children’s SUDs, and the strains that come with navigating barriers related to accessing treatment in the USA. Estimates suggest that healthcare spending for substance use treatment is relatively low and few utilize therapeutic family treatment. This disconnect between widespread SUD prevalence, and service underutilization, indicates that families who need treatment are not accessing it. The present paper synthesizes the extant literature on the role of family members in SUD treatment, as families are a primary context of care for their children’s treatment across many chronic, relapsing conditions. Finally, we identify the utility of family therapy in addressing family member’s unique needs related to their loved one with a SUD, in the family and in a treatment context.

Reducing health disparities among black individuals in the post-treatment environment

An important step in reducing health disparities among racial and ethnic minorities with substance use disorders involves identifying interventions that lead to successful recovery outcomes for this population. The current study evaluated outcomes of a community-based recovery support program for those with substance use disorders. Participants included 632 residents of recovery homes in three states in the US. A multi-item recovery factor was found to increase over time for these residents. However, rates of improvement among Black individuals were higher than for other racial/ethnic groups. Black Americans perhaps place a higher value on communal relationships relative to all other racial/ethnic groups, and by adopting such a communitarian perspective, they might be even more receptive to living in a house that values participation and involvement. The implications of these findings for health disparities research are discussed.

Recovery in Special Emphasis Populations

Special emphasis populations in the current context can be defined as groups experiencing health disparities resulting in elevated risk to health, safety, and well-being from drinking alcohol. Individuals from marginalized minority populations often encounter barriers to accessing and receiving effective alcohol treatment due to social inequities and disadvantaged life contexts, which also may adversely affect recovery from alcohol use disorder (AUD). Recovery from AUD often involves the adoption of a stable non-drinking lifestyle (sobriety), increased health and well-being, and increased social connection. Although there has been considerable work on AUD epidemiology among special emphasis populations, little research exists directly examining recovery among racial/ethnic minority populations and/or sexual and gender minority populations. The current narrative review hopes to spark scholarly interest in this critically neglected area. This article opens with a review of special emphasis populations and their alcohol-related risks. Next, definitions of recovery, Alcoholics Anonymous, and culturally adapted recovery models for racial/ethnic minority populations are explored. This is followed by a discussion of factors that may particularly influence recovery among marginalized minority populations. This narrative review concludes with a discussion of research priorities for promoting health equity through studies focused on understanding and supporting recovery from AUD among marginalized minority populations.

Factors associated with substance use disorder treatment completion: a cross-sectional analysis of justice-involved adolescents

Background

Substance use disorders (SUD) are prevalent among those in the juvenile justice system. SUD treatment programs implemented in correctional settings can prevent overdose and other health-related problems among an underserved health disparity population. However, only a fraction of justice-involved adolescents with SUDs complete a treatment program and the factors associated with treatment completion among adolescents in the criminal justice system have not been thoroughly investigated.

Methods

Using cross-sectional data on 25,587 adolescents from the Florida Department of Juvenile Justice (FLDJJ) who met the criteria for SUD treatment, the study investigated the factors associated with the completion of SUD treatment. Sociodemographic, mental health, and other variables were examined.

Results

Several factors were associated with an increased likelihood of SUD treatment completion: previous participation in treatment programs, prior drug and alcohol education class attendance, and involvement in court-directed programs. Additional factors included multiple incarcerations, and strong financial and support networks.

Conclusions

The strongest factors associated with a higher likelihood of SUD treatment completion among adolescents in the justice system are ones that can be translated into programs and practices. Repeated referrals to treatment, court-directed programs, and strong support networks may yield higher rates of completion.

Hispanic participants in the National Institute on Drug Abuse's Clinical Trials Network: A scoping review of two decades of research

INTRODUCTION

Hispanics significantly underutilize substance abuse treatment and are at greater risk for poor treatment outcomes and dropout. Two decades of research from the National Drug Abuse Treatment Clinical Trials Network (CTN) offers an opportunity to increase our understanding in how to address the disparities experienced by Hispanics in substance abuse treatment.

METHODS

A scoping review was utilized to determine what has been learned from the CTN about Hispanic populations with substance use disorder. A systematic search was conducted within the CTN Dissemination Library and nine databases. Potentially relevant studies were independently assessed by two reviewers for inclusion.

RESULTS

Twenty-four studies were included in the review. Results identified issues in measurement, characteristics of Hispanic substance use, effective interventions, and gaps for future research. Characteristics that interfere with treatment participation were also identified including low employment rates, less likelihood of having insurance, lower rates of internet access, and increased travel time to services, as were treatment issues such as high rates of alcohol and tobacco use. Effective interventions were identified; however, the effectiveness of these interventions may be limited to specific factors.

CONCLUSIONS

Despite efforts to improve inclusion of minority populations, Hispanics remain underrepresented in clinical trials. Future research including Hispanic populations should examine measurement equivalence and consider how cultural and historical experiences, as well as patient characteristics, influence utilization of services. Finally, more studies are needed that examine the impact of structural factors that act as barriers to treatment access and engagement and result in significant disparities in treatment outcomes.

The role of perceived treatment need in explaining racial/ethnic disparities in the use of substance abuse treatment services

OBJECTIVE

The current study examined the role of perceived treatment need in explaining racial/ethnic disparities in treatment utilization for a substance use disorder (SUD).

METHODS

We pooled data from the National Survey on Drug Use and Health survey for years 2014-2017. The analytic sample included adult white, Black, and Latino participants with a past-year SUD (n = 16,393). Multivariable logistic regressions examined racial/ethnic disparities in perceived treatment need-the perception of needing mental health and/or SUD treatment services within the past 12 months-and utilization of past-year substance use, mental health, and any treatment.

RESULTS

Latinos with SUD were less likely to perceive a need for treatment than whites. Black and Latino participants, relative to white participants, had lower odds of past-year treatment utilization, regardless of treatment type. In models stratified by perceived treatment need, racial/ethnic differences in the use of past-year SUD treatment and any treatment service were only significant among persons without a perceived need for treatment. We found no disparities in use of mental health treatment.

CONCLUSIONS

Adults with SUD have low perceived treatment need overall but especially among Latinos. Furthermore, Black and Latino disparities in SUD treatment use may be driven in part by lower perceived need for treatment. Interventions that promote better perceived need and delivery models that strengthen the integration of SUD treatment in mental health services may help to reduce these disparities.

Risk for Substance Use Disorders in young adulthood: Associations with developmental experiences of homelessness, foster care, and adverse childhood experiences

BACKGROUND

Multiple developmental risk factors for Substance Use Disorders (SUDs) during young adulthood have been identified. In this investigation, we examined the impact of homelessness, foster care, and adverse childhood experiences (ACEs) prior to 12th grade on the development of three common SUDs during young adulthood-Alcohol Use Disorder (AUD), Tobacco Use Disorder (TUD) and Cannabis Use Disorder (CUD). Our hypothesis was that while both homelessness and ACEs are significant risk factors for young adult SUDs, foster care involvement might convey protection.

METHODS

Using nationally representative data from the National Longitudinal Study of Adolescent to Adult Health, measures of ACEs were derived from the CDC-Kaiser ACE study, and DSM-V SUD diagnoses were derived from items originally based on DSM-IV. SUD diagnoses were binned into "mild", "moderate", and "severe" groupings. Survey-based logistic models were used to estimate risks of SUDs while controlling for demographics.

RESULTS

The results suggest that the experience of homelessness prior to 12th grade in addition to ACEs were significantly associated with the development in young adulthood of the most severe forms of AUD and TUD and all severity levels of CUD. Foster care was not associated with either risk or protection from SUDs.

CONCLUSIONS

The experience of homelessness during development may be viewed as another detrimental ACE that is a risk factor for the most common SUDs in young adulthood. Given the magnitude of the current epidemic of homelessness in the U.S., these results should raise substantial concern.

Development of a computerized adaptive substance use disorder scale for screening and measurement: the CAT-SUD

BACKGROUND AND AIMS

The focus of this paper is on the improvement of substance use disorder (SUD) screening and measurement. Using a multi-dimensional item response theory model, the bifactor model, we provide a psychometric harmonization between SUD, depression, anxiety, trauma, social isolation, functional impairment and risk-taking behavior symptom domains, providing a more balanced view of SUD. The aims are to (1) develop the item-bank, (2) calibrate the item-bank using a bifactor model that includes a primary dimension and symptom-specific subdomains, (3) administer using computerized adaptive testing (CAT) and (4) validate the CAT-SUD in Spanish and English in the United States and Spain.

DESIGN

Item bank construction, item calibration phase, CAT-SUD validation phase.

SETTING

Primary care, community clinics, emergency departments and patient-to-patient referrals in Spain (Barcelona and Madrid) and the United States (Boston and Los Angeles).

PARTICIPANTS/CASES

Calibration phase: the CAT-SUD was developed via simulation from complete item responses in 513 participants. Validation phase: 297 participants received the Composite International Diagnostic Interview (CIDI) and the CAT-SUD.

MEASUREMENTS

A total of 252 items from five subdomains: (1) SUD, (2) psychological disorders, (3) risky behavior, (4) functional impairment and (5) social support. CAT-SUD scale scores and CIDI SUD diagnosis.

FINDINGS

Calibration: the bifactor model provided excellent fit to the multi-dimensional item bank; 168 items had high loadings (> 0.4 with the majority > 0.6) on the primary SUD dimension. Using an average of 11 items (four to 26), which represents a 94% reduction in respondent burden (average administration time of approximately 2 minutes), we found a correlation of 0.91 with the 168-item scale (precision of 5 points on a 100-point scale).

VALIDATION

strong agreement was found between the primary CAT-SUD dimension estimate and the results of a structured clinical interview. There was a 20-fold increase in the likelihood of a CIDI SUD diagnosis across the range of the CAT-SUD (AUC = 0.85).

CONCLUSIONS

We have developed a new approach for the screening and measurement of SUD and related severity based on multi-dimensional item response theory. The bifactor model harmonized information from mental health, trauma, social support and traditional SUD items to provide a more complete characterization of SUD. The CAT-SUD is highly predictive of a current SUD diagnosis based on a structured clinical interview, and may be predictive of the development of SUD in the future.

Help seeking behaviors of Latinos with substance use disorders who perceive a need for treatment: Substance abuse versus mental health treatment services

OBJECTIVE

Perceiving a need for substance abuse treatment is a strong predictor of substance abuse treatment utilization among those with substance use disorders (SUD). Studies have found that when persons with SUD perceive a need for treatment, they are more likely to use mental health treatment rather than substance abuse treatment. Substance abuse treatment utilization is low among Latinos, relative to other racial/ethnic groups. It is unknown if Latinos with SUD who perceive a need for treatment are more likely to use mental health or substance abuse treatment.

METHODS

Data were pooled from the National Survey on Drug Use and Health survey years 2014, 2015, 2016, and 2017. Analyses were limited to adult Latino participants who met DSM-IV criteria for a past-year substance use disorder (n = 1889). Multinomial logistic regression analyses examined the role of perceived treatment need on the past-year use of (1) no treatment, (2) substance abuse treatment only, and (3) mental health treatment only. Important covariates included socio-demographics, problem severity, currently being on parole or probation, and poor mental health status.

RESULTS

Only 5% of Latinos with SUD reported perceiving a need for treatment. Treatment utilization was also low: 83% reported not using any treatment in the past-year. In multinomial logistic regressions, compared to not using any treatment, Latinos with SUD who perceived a need for substance abuse treatment were more likely to report using mental health treatment only. Perceiving a need for treatment and using substance abuse treatment services only was not statistically different from not using any treatment.

CONCLUSIONS

Findings underscore the need for better integration of substance abuse and mental health treatment services to address the health needs of Latinos.

Use of Drug Treatment Services Among Adults With Opioid Use Disorder: Rates, Patterns, and Correlates

OBJECTIVES

The study examined rates, patterns, and correlates of drug treatment services use among adults with opioid use disorder compared with adults with other drug use disorders.

METHODS

Data were from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, which surveyed a nationally representative sample of noninstitutionalized U.S. civilian adults. The proportions reporting drug treatment services use were compared between those with opioid use disorder and those with other drug use disorders. Multivariable-adjusted regression analyses identified factors associated with service use.

RESULTS

Adults with opioid use disorder (N=330, unweighted) reported a very low rate of any drug-related health services use (17.3%), although the rate was higher than among adults with other drug use disorders (7.4%) (p<0.001). Crisis-related services were the most common type of service used among adults with opioid use disorder (6.2%)-significantly higher than the rate among those with other drug use disorders (0.6%) (p<0.001). Few (3.3%) adults with opioid use disorder used outpatient drug treatment services. Among all adults with drug use disorders, opioid use disorder was associated with greater odds of using drug treatment services (adjusted odds ratio=2.43; 95% confidence interval=1.38-4.28). Living in the West and reporting moderate to extreme pain were associated with a lower likelihood of service use among all adults with drug use disorders (p<0.05 for each).

CONCLUSIONS

Most adults with opioid use disorder remain untreated, much less received outpatient treatment to address their addiction. Interventions are needed to improve access to and motivation for care among these vulnerable adults.

Racial and Ethnic Disparities in Autism-Related Health and Educational Services

OBJECTIVE

The objective of this study is to measure racial and ethnic disparities in autism-related services among U.S. children with parent-reported autism spectrum disorder (ASD).

METHODS

Using the 2011 Survey of Pathways to Diagnosis and Services, we analyzed parent-reported data on 1420 children with current ASD in the nationally representative sample. An estimation method consistent with the Institute of Medicine's definition of health care disparities is used to measure racial and ethnic disparities.

RESULTS

The findings revealed Latino-white disparities in the percentage of children currently using school-based occupational and physical therapy and Latino-white and "other race"-white disparities in the percentage of children using physical therapy outside of school. There were no statistically significant black-white disparities. Instead, the study found that the percentage of black children with ASD receiving school-based services was 8 points higher than that of white children (p < 0.04). Factors unrelated to the need for autism services were largely unassociated with the receipt of services.

CONCLUSION

The findings provide a partial baseline and identify a need for further examination of the source of existing disparities and the lack of disparities found for specific services and minority groups.

A current re-examination of racial/ethnic disparities in the use of substance abuse treatment: Do disparities persist?

OBJECTIVE

Racial/ethnic disparities in the use of substance abuse treatment services have been documented. The objective of this study was to re-examine if racial/ethnic disparities in the use of treatment still exist using current data collected post-implementation of the Affordable Care Act.

METHODS

Data were pooled from the National Survey on Drug Use and Health survey years 2015, 2016, and 2017. Analyses were limited to adult White, Black, and Latino participants who met DSM-IV criteria for a past-year substance use disorder (n = 12,070). Hierarchical multivariate logistic regression models examined the role of race/ethnicity on past-year use of (1) any substance abuse treatment services and (2) specialty treatment. Important covariates included socio-demographics, problem severity, and perceived treatment need. A sub-analysis was also conducted that was limited to participants who reported having health insurance to explore the role of insurance status on treatment utilization by race/ethnicity.

RESULTS

Findings showed that Latinos and Blacks significantly underutilized specialty treatment relative to Whites. These relationships were statistically significant after controlling for socio-demographic characteristics, problem severity, and perceived treatment need. However, when analyses were limited to only those with health insurance, Black-White disparities became non-significant, while Latino-White disparities persisted.

CONCLUSIONS

Findings highlight that Black-White and Latino-White disparities in the use of substance abuse treatment still persist. However, Black-White disparities may be limited to only those who are uninsured. Public health implications are discussed.

Race/Ethnicity, Community of Residence, and DUI Arrest After Beginning Treatment for an Alcohol Use Disorder

The purpose of this study was to examine whether racial/ethnic disparities in post-treatment arrests for driving under the influence (DUI) exist among clients receiving outpatient treatment for an alcohol use disorder (AUD) and to assess whether community characteristics were associated with this outcome. The sample included adults with an AUD entering publicly funded outpatient treatment in Washington State in 2012. Treatment data were linked with criminal justice and US Census data. Multilevel time-to-event analysis was employed to answer the research questions. Key independent variables included client race/ethnicity, community-level economic disadvantage, and racial/ethnic composition of the community. Latino clients and clients residing in communities with a higher proportion of Black residents had higher hazards of a DUI arrest post-treatment admission. Future research should examine whether disparities in DUI arrests are related to differences in treatment effectiveness or other factors (e.g., inequities in law enforcement) so that these disparities can be addressed.