Waiting for inpatient detoxification: A qualitative analysis of patient experiences

BACKGROUND

There is limited provision of inpatient detoxification relative to other treatments for alcohol and other drug (AOD) use. This means people often need to wait prior to detoxifying. However, waiting for healthcare is generally perceived as negative and stressful. This paper aims to understand patients' experiences of waiting for inpatient AOD detoxification to ascertain whether and how service-level policies and practices might be improved.

METHODS

Semi-structured telephone interviews were conducted with 32 people (20 males, 12 females; aged 25-67 years) who were waiting for inpatient detoxification. Data collection was part of a wider evaluation of a policy initiative started in 2021 to increase detoxification service capacity in England, UK. Interviews were professionally transcribed and data on waiting experiences were coded using qualitative software. Analyses were informed by new materialist thinking and undertaken via Iterative Categorisation.

RESULTS

We found that waiting was constituted through five dimensions: i. duration; ii. support; iii. information; iv. preparations; and v. emotions. These five dimensions were multi-faceted and operated in and through wider interacting social, material, and affective forces (e.g., professional judgements, formal and informal relationships, the availability of beds and funding, bureaucratic procedures, the utility and relevance of information, and participants' diverse feelings, including desperation for treatment). Not all accounts of waiting were negative. The experience was complex, non-uniform and variable over time. Moreover, it affected how people felt and how they behaved.

CONCLUSIONS

Changes to service-level policies and practices can potentially minimise the stress of waiting for inpatient AOD detoxification. The negative impact of waiting may be reduced if professionals more consistently engage patients in a wider range of constructive pre-treatment activities, offer regular 'check-ins' to mitigate any anxiety, explain changes in wait duration to help with planning and demonstrate fairness, and facilitate contact between those waiting to lessen feelings of isolation.

Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation

Background

Little is known about the stability of public drug treatment in the United States to deliver services in an era of expansion of public insurance. Guided by organizational theories, we examined the role of program size, and performance (i.e., rates of treatment initiation and engagement) on discontinuing services in one of the largest treatment systems in the United States.

Methods

This study relied on multi-year (2006–2014) administrative data of 249,029 treatment admission episodes from 482 treatment programs in Los Angeles County, CA. We relied on survival regression analysis to identify associations between program size, treatment initiation (wait time) and engagement (retention and completion rates) and discontinuing services in any given year. We examined program differences between discontinued versus sustained services in pre- and post-expansion periods.

Results

Sixty-two percent of programs discontinued services at some point between 2006 and 2014. Program size and rates of treatment retention were negatively associated with risk of discontinuing services. Proportion of female clients was also negatively associated with risk of discontinuing services. Compared to residential programs, methadone programs were associated with reduced likelihood of discontinuing services. Two interactions were significant; program size and retention rates, as well as program size and completion rates were negatively associated with risk of discontinuing services.

Conclusions

Program size (large), type (methadone), performance (retention) and client population (women) were associated with stability in this drug treatment system. Because more than 70% of programs in this system are small, it is critical to support their capacity to sustain services to reduce existing disparities in access to care. We discuss the implications of these findings for system evaluation and for responding to public health crises.

Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study

Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.

Program Capacity to Eliminate Outcome Disparities in Addiction Health Services

We evaluated program capacity factors associated with client outcomes in publicly funded substance abuse treatment organizations in one of the most populous and diverse regions of the United States. Using multilevel cross-sectional analyses of program data (n = 97) merged with client data from 2010 to 2011 for adults (n = 8,599), we examined the relationships between program capacity (leadership, readiness for change, and Medi-Cal payment acceptance) and client wait time and treatment duration. Acceptance of Medi-Cal was associated with shorter wait times, whereas organizational readiness for change was positively related to treatment duration. Staff attributes were negatively related to treatment duration. Overall, compared to low program capacity, high program capacity was negatively associated with wait time and positively related to treatment duration. In conclusion, program capacity, an organizational indicator of performance, plays a significant role in access to and duration of treatment. Implications for health care reform implementation in relation to expansion of public health insurance and capacity building to promote health equities are discussed.

Waiting Time as a Barrier to Treatment Entry: Perceptions of Substance Users

Many substance users report that they experience multiple barriers that produce significant challenges to linking with treatment services. Being on a waiting list is frequently mentioned as a barrier, leading some people to give up on treatment and to continue using, while prompting others to view sobriety during the waiting period as proof they do not need treatment. This ethnographic study examines the views that 52 substance users have of the waiting time before treatment and the strategies they created to overcome it. Understanding how substance users react to waiting time itself and in relation to other barriers can lead to services that are effective in encouraging treatment linkage.

The Multidimensional Structure of Internal Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age

The goal of the present study was to identify the dimensions present in items representing internal barriers to substance abuse treatment and to test their invariance across gender, ethnic, and age groups. Twenty items from the Barriers to Treatment Inventory (BTI) were used to assess the structure and nature of the internal treatment barriers of 518 clients presenting to a central intake unit for a substance abuse assessment. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) revealed that a five factor model provided the best fit to the data. Internal treatment barriers were best described by five dimensions: absence of problem, negative social support, fear of treatment, privacy concerns, and committed lifestyle. Extending the confirmatory factor analysis to test multi-group invariance, there were some differences in measurement and structural relations among the internal barrier dimensions across gender, ethnic, and age groups. However, the lack of invariance was small and practically insubstantial. The findings led to the conclusion that the theoretical constructs measured by the five internal barrier dimensions are equivalent across important characteristics in this population.

Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs

INTRODUCTION AND AIMS

Research on perceived unmet need for care for mental health and substance use problems focuses on general populations to the detriment of hidden populations. This study describes prevalence and correlates of perceived unmet need for care in a community-based sample of street-involved people who use illicit drugs and identifies barriers to care.

DESIGN AND METHODS

A sample of 320 street-involved people who use drugs participated in a structured, interviewer-assisted survey in Edmonton, Canada. The survey included the Perceived Need for Care Questionnaire, which assessed unmet need for care for mental health and substance use problems across seven service types. Logistic regression examined the associations between perceived unmet need, extent of socioeconomic marginalisation and problem severity. Barriers underlying unmet service needs were also examined.

RESULTS

Most (82%) participants reported unmet need for one or more services during the past year. Odds of reporting one or more unmet needs were elevated amongst participants reporting substantial housing instability (adjusted odds ratio = 2.37; 95% confidence interval 1.19-4.28) and amongst participants meeting criteria for drug dependence (adjusted odds ratio = 1.22; 95% confidence interval 1.03-1.50), even after adjustment for sociodemographic covariates. Structural, rather than motivational barriers were the most commonly reported reasons underlying unmet service needs.

DISCUSSION AND CONCLUSION

Street-involved people who use drugs experience very high rates of perceived unmet need for care for mental health and substance use problems. General population studies on perceived unmet need are insufficient for understanding needs and barriers to care in hidden populations.[Hyshka E, Anderson JT, Wild TC. Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs. Drug Alcohol Rev 2017;36:295-304].

Co-Morbidities Among Persons With Substance Abuse Problems

This article uses the behavioral model for vulnerable populations to evaluate the use of substance abuse treatment services among a sample of 926 substance abusers with one or more vulnerable health designations. A two-stage hierarchical logistic regression was completed to determine the influence of vulnerable and traditional need factors on the probability of receiving substance abuse treatment. Among traditional covariates, increased odds of receiving substance abuse treatment are associated with being either non-Hispanic White, Hispanic, having an income > US$5,000, and having a regular source of care. Among vulnerable covariates, injection drug use (odds ratio [OR] = 2.19, confidence interval [CI] = [1.46, 3.27]) and the receipt of public benefits (OR = 1.98, CI = [135, 2.92]) remain independent risk factors for the receipt of substance abuse treatment. Many who experience substance abuse disorders can also experience a multitude of other vulnerable health classifications, suggesting the need for a comprehensive, multidisciplinary approach to the treatment of substance use disorders.

Paths to improving engagement among racial and ethnic minorities in addiction health services

Background

Members of racial and ethnic minority groups are most likely to experience limited access and poor engagement in addiction treatment. Research has been limited on the role of program capacity and delivery of comprehensive care in improving access and retention among minorities with drug abuse issues. The goal of this study was to examine the extent to which access and retention are enhanced when racial and ethnic minorities receive care from high-capacity addiction health services (AHS) programs and via coordination with mental health and receipt of HIV testing services.

Methods

This multilevel cross-sectional analysis involved data from 108 programs merged with client data from 2011 for 13,478 adults entering AHS. Multilevel negative binomial regression models were used to test interactions and indirect relationships between program capacity and days to enter treatment (wait time) and days in treatment (retention).

Results

Compared to low-capacity programs and non-Latino and non-African American clients, Latinos and African Americans served in high-capacity programs reported shorter wait times to admission, as hypothesized. African Americans also had longer treatment retention in high-capacity programs. Receipt of HIV testing and program coordination of mental health services played an indirect role in the relationship between program capacity and wait time.

Conclusions

Program capacity and coordinated services in AHS may reduce disparities in access to care. Implications for supporting low-capacity programs to eliminate the disparity gap in access to care are discussed.

Inability to access addiction treatment among street-involved youth in a Canadian setting

From Sept 2005 to May 2012, 1015 street-involved youth were enrolled into the At-Risk Youth Study, a prospective cohort of youth aged 14-26 who use illicit drugs in Vancouver, Canada. Data were collected through semiannual interviewer administered questionnaires. Generalized estimating equation logistic regression was used to identify factors independently associated with being unable to access addiction treatment. The enclosed manuscript notes the implications and limitations of this study, as well as possible directions for future research. This study was funded by the US National Institutes of Health (NIH) and Canadian Institutes of Health (CIHR).

Enhancing access and retention in substance abuse treatment: the role of Medicaid payment acceptance and cultural competence

BACKGROUND

Health insurance coverage and quality of care are common factors believed to improve access for and retention of racial and ethnic minority groups in health care. However, there is little evidence that acceptance of public insurance and provision of culturally responsive care decrease wait time and retention of minority populations in community-based substance abuse treatment.

METHODS

We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, CA. An analytical sample of 13,328 primarily African American and Latino clients nested within 104 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on count measures of days to initiate and days spent in treatment.

RESULTS

Programs that accepted public insurance (p<.001) and in which staff reported personal involvement (p<.01) and linkages and resources with minority communities (p<.001) were negatively associated with client wait time. Similarly, programs with culturally responsive policies and assessment and treatment practices (p<.05) were positively associated with retention in treatment, after controlling for individual and program characteristics.

CONCLUSIONS

These preliminary findings provide an evidentiary base for the role of community-based financial and cultural practices in improving accessibility and treatment adherence in a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to expand public insurance and enhance culturally competent care, are discussed.

Client and program characteristics associated with wait time to substance abuse treatment entry

BACKGROUND

Wait time is among the most commonly cited barriers to access among individuals seeking entry to substance abuse treatment, yet relatively little is known about what contributes to it.

OBJECTIVES

To address this gap, this study draws from a national sample of substance abuse treatment clients and programs to estimate the proportion of clients entering treatment who waited more than 1 month to receive it (outpatient, residential, or methadone) and to identify client and program characteristics associated with wait time.

METHODS

This study used data from the National Treatment Improvement Evaluation Study (1992-1997). The data include 2920 clients from 57 substance abuse treatment programs. Generalized linear modeling was used to identify client and program characteristics associated with wait time to treatment entry.

RESULTS

Results of modeling indicate that being African-American (OR: 1.40; CI: 1.04, 1.88), being referred by criminal justice (OR: 1.70; CI: 1.18, 2.43), and receiving methadone (OR: 3.90; CI: 1.00, 15.16) were associated with increased odds of waiting more than 1 month. Conversely, having a diagnosis of HIV/AIDS (OR: 0.38; CI: 0.19, 0.77) was associated with decreased odds of waiting for more than 1 month.

CONCLUSION

A significant proportion of clients waited more than 1 month on enter treatment. Greater odds of such wait times were associated with being African-American, criminal justice-referred, and receiving methadone.

SIGNIFICANCE

This study is the first to use a national sample to examine the prevalence of wait time to substance abuse treatment entry and to identify client and program characteristics associated with it.

Long waiting period to enter methadone maintenance treatment: relation to patient characteristics and outcome

Methadone maintenance treatment is a chronic treatment for opiate addicts. After having reached full capacity, new admissions to our clinic were delayed (through a waiting list) for all but opiate addicts with HIV and pregnant women. We compared characteristics and outcomes between patients admitted without delay (1993-2002) and those admitted through a waiting list (2003-2009). All 704 patients admitted between June 1993 and June 2009 were followed up until June 2010. There were 470 patients in the early period and 234 in the late period (56 patients were admitted immediately and 178 after 1.1 ± 0.8 years of waiting). Predictors for 1-year retention in treatment (logistic regression model) were if a patient self-referred during the late period, on a waiting list. The waiting list patient group was characterized by older age and self-referral - two known independent predictors of better retention that were attributed to their superior retention rate.

A business case for quality improvement in addiction treatment: evidence from the NIATx collaborative

The Network for the Improvement of Addiction Treatment (NIATx) promotes treatment access and retention through a customer-focused quality improvement model. This paper explores the issue of the "business case" for quality improvement in addiction treatment from the provider's perspective. The business case model developed in this paper is based on case examples of early NIATx participants coupled with a review of the literature. Process inefficiencies indicated by long waiting times, high no-show rates, and low continuation rates cause underutilization of capacity and prevent optimal financial performance. By adopting customer-focused practices aimed at removing barriers to treatment access and retention, providers may be able to improve financial performance, increase staff retention, and gain long-term strategic advantage.

Adolescent substance abuse treatment: Organizational change and quality of care

Substance abuse treatment agencies serving youth face unique barriers to providing quality care. Interviews with 17 adolescent programs found that family engagement, community involvement, and gender and diversity issues impacted treatment delivery. Programs report organizational change efforts with implications for future process improvement initiatives.

Cultural competence in outpatient substance abuse treatment: measurement and relationship to wait time and retention

BACKGROUND

Culturally competent practice is broadly acknowledged to be an important strategy to increase the quality of services for racial/ethnic minorities in substance abuse treatment. However, few empirically derived measures of organizational cultural competence exist, and relatively little is known about how these measures affect treatment outcomes.

METHOD

Using a nationally representative sample of outpatient substance abuse treatment (OSAT) programs, this study used item response theory to create two measures of cultural competence-organizational practices and managers' culturally sensitive beliefs-and examined their relationship to client wait time and retention using Poisson regression modeling.

RESULTS

The most common and precisely measured organizational practices reported by OSAT managers included matching providers and clients based on language/dialect; offering cross-cultural training; and fostering connections with community and faith-based organizations connected to racial and ethnic minority groups. The most culturally sensitive belief among OSAT managers was support for language/dialect matching for racial and ethnic minority clients. Results of regression modeling indicate that organizational practices were not related to either outcome. However, managers' culturally sensitive beliefs were negatively associated with average wait time (p<0.05), and positively associated with average retention (p<0.01).

CONCLUSIONS

Managers' culturally sensitive beliefs-considered to be influential for effective implementation of culturally competent practices-may be particularly relevant in influencing wait time and retention in OSAT organizations that treat Latinos and African American clients.

Days to treatment and early retention among patients in treatment for alcohol and drug disorders

OBJECTIVES

Drug and alcohol treatment programs often have long delays between assessment and treatment admission. The study examined the impact of days to treatment admission on the probability of completing four sessions of care within an addiction treatment program implementing improvements in their admission process.

METHODS

Mixed-effects logistic regression was used to test the effect of wait time on retention in care.

RESULTS

Findings demonstrate a strong decrement in the probability of completing four sessions of treatment with increasing time between the clinical assessment and first treatment session.

Inability to access addiction treatment and risk of HIV infection among injection drug users recruited from a supervised injection facility

BACKGROUND

Treatment for drug addiction is effective in reducing the harms of injection drug use, including infection with HIV and/or hepatitis C. We sought to examine the prevalence and correlates of being unable to access addiction treatment in a representative sample of injection drug users randomly recruited from a supervised injection facility.

METHODS

Using generalized estimating equations, we determined the prevalence and factors associated with being unable to access addiction treatment.

RESULTS

Between 1 July 2004 and 30 June 2006, 889 individuals completed at least one interview and were included in this analysis. At each interview, approximately 20% of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months. Being unable to access treatment was independently associated with recent incarceration, daily use of heroin and borrowing used syringes. In a secondary question, the majority of individuals reported waiting lists were the reason for being unable to access treatment.

CONCLUSION

Given the independent association between inability to access addiction treatment and elevated HIV risk behavior, these results suggest expanding addiction treatment may contribute significantly to HIV prevention efforts in this population.

Attitudes toward methadone among out-of-treatment minority injection drug users: implications for health disparities

Injection drug use (IDU) continues to be a significant public health issue in the U.S. and internationally, and there is evidence to suggest that the burden of injection drug use and associated morbidity and mortality falls disproportionately on minority communities. IDU is responsible for a significant portion of new and existing HIV/AIDS cases in many parts of the world. In the U.S., the prevalence of HIV and hepatitis C virus is higher among populations of African-American and Latino injection drug users (IDUs) than among white IDUs. Methadone maintenance therapy (MMT) has been demonstrated to effectively reduce opiate use, HIV risk behaviors and transmission, general mortality and criminal behavior, but opiate-dependent minorities are less likely to access MMT than whites. A better understanding of the obstacles minority IDUs face accessing treatment is needed to engage racial and ethnic disparities in IDU as well as drug-related morbidity and mortality. In this study, we explore knowledge, attitudes and beliefs about methadone among 53 out-of-treatment Latino and African-American IDUs in Providence, RI. Our findings suggest that negative perceptions of methadone persist among racial and ethnic minority IDUs in Providence, including beliefs that methadone is detrimental to health and that people should attempt to discontinue methadone treatment. Additional potential obstacles to entering methadone therapy include cost and the difficulty of regularly attending a methadone clinic as well as the belief that an individual on MMT is not abstinent from drugs. Substance use researchers and treatment professionals should engage minority communities, particularly Latino communities, in order to better understand the treatment needs of a diverse population, develop culturally appropriate MMT programs, and raise awareness of the benefits of MMT.

Barriers to formal drug abuse treatment in the rural south: a preliminary ethnographic assessment

This article describes barriers to obtaining drug abuse treatment in the rural South using qualitative interviews conducted with 86 illicit stimulant users recruited in rural Arkansas and Kentucky between 2003 and 2005. Fifty-nine (69.0%) of the interviewees had never entered drug abuse treatment. Sixteen (19.0%) participants reported current perceived need for treatment, while seven (8%) were ambivalent about seeking it. Interview data suggest five interrelated categories of barriers to accessing drug abuse treatment: (1) geographical, (2) organizational, (3) economic, (4) social, and (5) psychological. The study findings can inform further examination of rural treatment barriers and have important implications for developing strategies to overcome these obstacles.

Improving linkage with substance abuse treatment using brief case management and motivational interviewing

BACKGROUND

Poor linkage with substance abuse treatment remains a problem, negating the benefits that can accrue to both substance abusers and the larger society. Numerous behavioral interventions have been tested to determine their potential role in improving linkage.

METHODS

A randomized clinical trial of 678 substance abusers compared the linkage effect of two brief interventions with the referral standard of care (SOC) at a centralized intake unit (CIU). Interventions included five sessions of strengths-based case management (SBCM) or one session of motivational interviewing (MI). A priori hypotheses predicted that both interventions would be better than the standard of care in predicting linkage and that SBCM would be more effective than MI. We analyzed the effect of the two interventions on overall treatment linkage rates and by treatment modality. Logistic regression analysis examined predictors of treatment linkage for the sample and each group.

RESULTS

Two hypotheses were confirmed in that SBCM (n=222) was effective in improving linkage compared to the SOC (n=230), 55.0% vs. 38.7% (p<.01). SBCM improved linkage more than MI (55.0% vs. 44.7%, p<.05). Motivational interviewing (n=226) was not significantly more effective in improving linkage than the standard of care (44.7% vs. 38.7%; p>.05). The three trial groups differed only slightly on the client characteristics that predicted linkage with treatment.

CONCLUSIONS

The results of this study confirm a body of literature that supports the effectiveness of case management in improving linkage with treatment. The role of motivational interviewing in improving linkage was not supported. Results are discussed in the context of other case management and motivational interviewing linkage studies.

Barriers to accessing generic health and social care services: a qualitative study of injecting drug users

While research has clearly documented the difficulties injectors encounter in accessing specialist addiction services, there is less evidence of the problems they face when securing general health care and non-substance-misuse-specific support. This paper seeks to fill some of these knowledge gaps. Between January and May 2006, 75 current injectors were recruited and interviewed through three needle exchange programmes located in diverse geographical areas of West Yorkshire. Interview data were transcribed verbatim and analysed using Framework. Findings showed that injectors were often positive about the help they received from generic health and social care services. Nonetheless, they identified a range of barriers relating to inability to access desired assistance, the burden of appointments, travel to services, stigma and negative staff attitudes, personal ill-health, lack of material resources, and anxieties about accessing support. Although some types of barriers were more evident at some services than at others and/or affected particular subgroups of injector more than others, the impact of any barrier was contingent on a range of factors. These included the attitudes of individual professionals, the circumstances and needs of individual injectors, the local availability of suitable alternative services, and the frequency with which a service needed to be accessed. In order to better understand and potentially reduce service barriers, findings are linked to broader conceptual and theoretical debates relating to social exclusion and Foucault's analyses of power and knowledge.

Access to drug abuse treatment under Treatment on Demand policy in San Francisco

OBJECTIVES

We evaluated whether implementation of Treatment on Demand (TOD) policy in San Francisco was associated with improved access to drug abuse treatment.

METHODS

Data came from San Francisco's treatment program waiting list over 4 years spanning the implementation of TOD policy. Access measures were monthly applicants waiting and days waited by treatment admissions. Quantitative analyses with 69 treatment facilities contrasted those receiving vs. not receiving TOD funds. Qualitative data came from interviews with facility administrators.

RESULTS

There was a small statistically significant decline in monthly waiting lists in the number of people waiting for treatment during the study period. The days waited by those admitted to treatment, however, significantly increased in TOD-funded facilities. Facilities used varied criteria for completing the access measures, which limit the utility of the measures.

CONCLUSIONS

Access to treatment improved slightly with implementation of TOD policy.

Equity of access to treatment, and barriers to treatment for illicit drug use in Australia

AIMS AND DESIGN

This study investigated equity of access to treatment and barriers to treatment for illicit drug use, using Andersen's behavioural model of health service utilization.

SETTING AND PARTICIPANTS

The study involved 492 drug users who had received treatment and 193 who had not.

MEASUREMENTS

Participants were interviewed to gather data relating to 19 predisposing, need and enabling variables.

FINDINGS

Never-treated participants exhibited less need for treatment than those who had received treatment. They experienced less negative emotion, used their main drug less often, had fewer drug-related health problems and fewer drug-using friends, were less likely to have blood-borne virus infections and were more likely to be using drugs for 'fun'. They also had more negative attitudes towards drug treatment staff, were less likely to believe that appropriate treatment was available and less likely to believe that professional help was necessary to get off drugs. Prevalence of physical and mental health problems was high in both groups.

CONCLUSIONS

The study documented significant unmet treatment need and identified several sources of inequity and barriers to treatment that would be amenable to policy and service development. Drug user organizations and peer educators and motivational interventions in primary care settings should be utilized to market the nature and benefits of treatment effectively, and to address the causes of drug users' negative attitudes towards treatment.

Individual and system influences on waiting time for substance abuse treatment

Waiting time is a contemporary reality of many drug abuse treatment programs, resulting in substantial problems for substance users and society. Individual and system factors that influence waiting time are diverse and may vary at different points in the treatment continuum. This study assessed waiting time preceding clinical assessment at a centralized intake unit and during the period after the assessment but before treatment entry. The present study included 577 substance abusers who were enrolled in a large clinical trial of two brief treatment interventions in a midsize metropolitan area in Ohio. Bivariate analyses identified individual and system factors that influenced preassessment and postassessment waiting time, as well as total wait to treatment services. Multivariate analyses demonstrated that longer wait time for an assessment is influenced by being court referred, less belief in having a substance abuse problem, and less desire for change. A shorter wait to actually enter treatment is predicted by having a case manager, being more ready for treatment, and having less severe employment and alcohol problems. The different influences present during the two waiting periods suggest that assessment and treatment programs need to implement system changes and entry enhancement interventions that are specific to the needs of substance abusers at each waiting period.

Process improvement needs in substance abuse treatment: admissions walk-through results

Researchers have questioned whether the addiction treatment infrastructure will be able to deliver high-quality care to the large numbers of people in need. In this context, the Robert Wood Johnson Foundation and the Center for Substance Abuse Treatment created a nationwide network to improve access and retention in treatment. Applicant agencies described results of an admission process walk-through. This qualitative study used narrative text from 327 applications to the Robert Wood Johnson Foundation, focusing on admissions-related problems. We developed and applied a coding scheme and then extracted themes from code-derived text. Primary themes described problems reported during treatment admissions: poor staff engagement with clients; burdensome procedures and processes; difficulties with addressing the clients' complex lives and needs; and infrastructure problems. Subthemes elucidated specific process-related problems. Although the findings from our analyses are descriptive and exploratory, they suggest the value of walk-through exercises for program assessment and program-level factors that may affect treatment access and retention.

Making “Stone Soup”: Improvements in Clinic Access and Retention in Addiction Treatment

BACKGROUND

The Network for Improvement of Addiction Treatment (NIATx) provides 39 treatment organizations with collaborative learning opportunities and technical support to reduce waiting time between the first request for service and the first treatment session, reduce the number of patients who do not keep an appointment (no-shows), increase the number of people admitted to treatment, and increase continuation from the first through the fourth treatment session. ACADIA'S STORY-TREATMENT ON DEMAND: Given capacity constraints, only 25% of the clients scheduled for outpatient care at Acadia Hospital (Bangor, Maine) showed up for their assessment appointments, and only 19% made it into treatment. A variety of changes were introduced, including increasing staff availability to provide clients with assessments immediately on arrival (at 7:30 A.M.), establishing a clinician pool to handle client overflow, and allowing for same-day admission to intensive outpatient or chemical dependency services. These process improvements reduced the time from first contact to the first treatment session from 4.1 to 1.3 days (68%), reduced client no-shows, and increased continuation in treatment and transfers across levels of care.

DISCUSSION

The successes experienced by organizations in the NIATx initiative should be useful for implementing change in other fields of service delivery.

Improving drug treatment services for Hispanics: research gaps and scientific opportunities

Delivery of services to Hispanic drug users remains a great challenge, as shown by low service access and retention, and disproportionate negative consequences of drug abuse in the Hispanic population. This paper provides a critical analysis of current services research on Hispanics with drug abuse problems, identifies gaps in the knowledge, and offers recommendations for scientific opportunities to address these gaps, focusing on four central needs: (1) the need to understand the circumstances of Hispanics in their own communities (i.e., community context); (2) the need to develop and test service delivery models tailored to Hispanics' circumstances and special needs; (3) the need to remove client, provider, and system barriers to utilization; and (4) the need to establish links between drug abuse services, social services, and other service sectors to optimize treatment outcomes. The authors suggest an approach that begins with a focus on the local Hispanic community and builds understanding of the cultural context, inclusion of indigenous resources, recognition of barriers to enrollment and retention, and coordination of related services.

Medicaid coverage and access to publicly funded opiate treatment

This observational study examines changes in access to methadone maintenance treatment following Oregon's decision to remove substance abuse treatment from the Medicaid benefit for an expansion population. Access was compared before and after the benefit change for two cohorts of adults addicted to opiates presenting for publicly funded treatment. Propensity score analysis helped model some selective disenrollment from Medicaid that occurred after the benefit change. Logistic regression was used to compare access to methadone by cohort controlling for client characteristics. Opiate users presenting for publicly funded treatment after the change were less than half as likely (OR = 0.40) to be placed in an opiate treatment program compared to the prior year. Further analysis revealed that those with no recent treatment history were less likely to present for treatment after the benefit change. These results have implications for states considering Medicaid cuts, especially if the anticipated increases in illegal activity, emergency room utilization, unemployment, and mortality can be demonstrated.

Treatment barriers identified by substance abusers assessed at a centralized intake unit

The 59-item Barriers to Treatment Inventory (BTI) was administered to 312 substance abusers at a centralized intake unit following assessment but before treatment entry to assess their views on barriers to treatment. Factor analysis identified 25 items in 7 well-defined latent constructs: Absence of Problem, Negative Social Support, Fear of Treatment, Privacy Concerns, Time Conflict, Poor Treatment Availability, and Admission Difficulty. The factorial structure of the barriers is consistent with the findings of other studies that asked substance abusers about barriers to treatment and is conceptually compatible with Andersen's model of health care utilization. Factors were moderately to highly correlated, suggesting that they interact with one another. Selected characteristics were generally not predictive of barrier factors. Overall, results indicate that the BTI has good content validity and is a reliable instrument for assessing barriers to drug treatment. The potential utility of the BTI in assessment settings is discussed.

Access to publicly funded methadone maintenance treatment in two western states

This study examined individual and system characteristics associated with access to methadone maintenance treatment (MMT) among Medicaid-eligible adults entering treatment for opiate use in Oregon and Washington. Logistic regression was used to examine the relative contributions of predisposing, need, and enabling characteristics on access to MMT. Although the number of methadone admissions increased in both states, access rates (the percentage of opiate-using adults presenting for treatment who were placed on methadone) declined after 1995. Adults in remote counties were one fifth to one tenth as likely to be placed in a methadone maintenance program than those living in counties with a methadone clinic. Other significant barriers to access included polydrug use, legal system referral, residence in a group home, lack of income, and homelessness. Factors promoting access included prior methadone use, pregnancy, and self-referral to treatment. These results suggest that more can be done to expand access to methadone maintenance.

Demystifying the injection drug user: willingness to participate in traditional drug treatment services among participants in a needle exchange program

Injection drug users have been vilified in our culture as being wild-eyed and willing to do anything for the next hit. These individuals are typically seen as being unemployed, uneducated and completely disinterested in making any changes in their lives. Sixty-one participants in a syringe exchange program in Cleveland, Ohio were interviewed using the NIDA Risk Behavior Assessment. Fifty (81%) of the respondents were either in an abstinence-based program or reported a willingness to participate in such a program. Importantly, although the sample consisted of long-term daily users of injection drugs (m=19.95 years), the majority of the sample was employed (69%) and were high school graduates (51%). The results of this study suggest that injection drug users are willing to make changes in their use-related behaviors, involvement in a needle exchange program does not preclude involvement in abstinence-based programming, and needle exchange services may serve as an important component in a continuum of care when coupled with traditional abstinence-based services.

A descriptive profile of health problems, health services utilization, and HIV serostatus among incarcerated male drug abusers

The number of incarcerated offenders is increasing, and many have physical and mental health problems. Drug-involved prisoners exhibit more health problems and greater rates of chronic health problems than prisoners who have not used drugs. Furthermore, human immunodeficiency virus (HIV) prevalence rates are generally high in prisons. This descriptive study profiles health problems (including HIV) and health services utilization in a sample of drug-involved prisoners from a rural state. HIV seropositivity appeared to be unrelated to drug use, except for marijuana use. Only liver problems were significantly associated with HIV serostatus. A history of mental health treatment was related to a greater likelihood of being HIV+. HIV status was most clearly associated with sexual risk behaviors. These preliminary findings suggest that prisons represent an important site for targeted behavioral health interventions focused on HIV risk reduction.

Use of HIV health care in HIV-seropositive crack cocaine smokers and other active drug users

PURPOSE

We assessed the use of HIV care among HIV-seropositive crack cocaine smokers and other active drug users in Miami-Dade County, FL.

METHODS

Personal interviews were conducted with 327 adults recruited from inner city neighborhoods. Cross-tabulations and logistic modeling were used to analyze the relationship between selected variables and use of HIV care.

RESULTS

One-third of respondents had not seen a provider for HIV-related health care in the past 12 months. Among those who had seen a provider, only 33.8% were receiving highly active antiretroviral therapy (HAART). Factors associated with utilization of HIV-related health care were age, race, having a usual source of care, health insurance, time elapsed since time of diagnosis, and reports of moderate to extreme interference of pain with daily activities.

IMPLICATIONS

These findings suggest the need to develop, implement, and evaluate intervention strategies to improve use of HIV medical care among active drug users.