Differences in service utilization and barriers among Blacks, Hispanics, and Whites with drug use disorders

The ACA Medicaid expansions and the supply of substance use disorder treatment services in Spanish

BACKGROUND

Given persistent disparities in substance use disorder (SUD) treatment for Spanish speakers, it is important to understand whether major health policy changes may improve access to linguistically competent services. We estimate changes in the supply of SUD treatment facilities that both accept Medicaid as payment and offer services in Spanish after the Medicaid expansions under the Affordable Care Act.

METHODS

We use data from the Mental Health and Addiction Treatment Tracking Repository for years 2010-2020 to calculate the number of facilities per 100 that offered both services in Spanish and accepted Medicaid as payment, facilities per 100 that accepted Medicaid as a form of payment overall, and facilities per 100 that offered Spanish language services overall. We use a difference-in-differences strategy exploiting variation in the timing of the Medicaid expansions across states, and county-level variation in the share of Spanish speaking Latinos across and within states.

RESULTS

We find that treatment facilities that both accepted Medicaid as a form of payment and offered Spanish language services increased by roughly 2-3 per 100, on average, in counties with the highest shares of Spanish speakers compared to counties with low to medium shares. This increase may be explained by more facilities accepting Medicaid as a form of payment.

CONCLUSION

The Medicaid expansions under the ACA produced a modest increase in the supply of SUD treatment facilities that both accepted Medicaid as payment and provided services in Spanish in areas with highest shares of Spanish speakers.

Missing Opportunities in the Screening of Alcohol Use and Problematic Use, and the Provision of Brief Advice and Treatment Information Among Individuals With Alcohol Use Disorder

OBJECTIVES

The aim of this study was to identify sociodemographic and substance-related factors associated with being screened, receiving advice or treatment information from healthcare providers, among individuals who met the criteria for the past 12-month alcohol use disorder (AUD).

METHODS

The 2015-2019 National Survey on Drug Use and Health data were analyzed to identify factors associated with being (1) asked about alcohol used among adults with AUD, who visited a healthcare provider within the past 12 months, and were not receiving AUD treatment (sample 1, n = 13,321); (2) asked about problematic use; (3) advised to reduce consumption; and (4) offered alcohol treatment information, among those in sample 1 who were asked about their use (n = 6,905).

RESULTS

About half (52.9%) in sample 1 were asked about their alcohol use. Among them, 21.6% were asked about problematic use, 17.7% were advised to reduce alcohol consumption, and 7.6% were offered information. The odds of being asked about alcohol use among male participants were 0.72 times the odds of female participants; however once asked, male participants showed greater odds of being asked about problematic use (adjusted odds ratio [aOR] = 1.53, 95% confidence interval [CI] = 1.29-1.82), advised to reduce consumption (aOR = 1.64, 95% CI = 1.24-2.16), and offered treatment information (aOR = 1.77, 95% CI = 1.34-2.35). As compared with non-Hispanic White participants, other racial/ethnic groups were less likely to be asked about alcohol use; however, once asked, no differences were observed for other outcomes.

CONCLUSIONS

Significant gaps in the screening and provision of advice or treatment information were identified, particularly for racial/ethnic and sex subgroups. Reducing barriers for effective screening could help address AUD-related disparities.

Risk factors of substance use treatment gaps among a nationally representative sample of black American adults in relation to sexual minority status and health insurance coverage

BACKGROUND

Little research has investigated predictors of specialty substance use treatment gaps among Black adults. This study examined differential odds of experiencing self-reported, past-year treatment gaps among Black adults with respect to sexual minority status and health insurance coverage, accounting for social cofactors.

METHOD

This cross-sectional study comprised 36,098 Black Americans aged 18 and older who completed the 2015-2019 National Survey on Drug Use and Health (NSDUH) and provided responses for all selected survey items. Design-based multivariable logistic regression models were used to examine predictors of drug and alcohol treatment gaps.

RESULTS

Sexual minority Black adults reported greater odds of experiencing treatment gaps to specialty treatment (i.e., inpatient hospital, inpatient/outpatient rehabilitation facility, or mental health center) compared to Black heterosexuals in adjusted models (Gay or lesbian: AOR = 2.01, 95% CI = 1.39-2.89; Bisexual: AOR = 2.35, 95% CI = 1.77-3.12), with bisexual Black women experiencing the greatest odds (AOR = 3.10, 95% CI = 2.33-4.14). Black adults with no health insurance were significantly more likely to report substance use treatment gaps relative to their peers with health insurance coverage (AOR = 50, 95% CI = 1.26-1.78).

CONCLUSION

The results suggest a critical need for more investigations into patterns of specialty substance use treatment gaps within Black populations and for developing sexual identity-affirming mechanisms for closing the disparity gap, particularly for Black sexual minorities and those who lack health insurance coverage.

Racial and ethnic inequities in substance use treatment among women with opioid use disorder

Background: Research describes inequities in substance use treatment, but few studies focus specifically on racial and ethnic disparities in a range of aspects of substance use treatment among women with opioid use disorder (OUD).Objective: To examine whether substance use treatment (i.e. receipt, sources, barriers) differs by race and ethnicity among women with opioid use disorder (OUD) and to identify factors associated with treatment gap (i.e. needing treatment but not receiving it).Methods: We performed cross-sectional analyses using National Survey on Drug Use and Health 2015-2019 data, restricted to non-Hispanic Black, non-Hispanic White, and Hispanic women with past-year OUD (unweighted n = 1089). We estimated the prevalence of aspects of treatment among racial and ethnic groups, and used modified Poisson regression to estimate correlates of reported treatment gap.Results: Approximately 68% of White versus 87% of Black and 81% of Hispanic women with OUD had a treatment gap (p-value 0.0034). Commonly reported barriers to treatment included prioritization, affordability, and stigma. Older age was associated with lower prevalence of treatment gap among all women [prevalence ratio (PR) = 0.83, and 95% confidence interval (CI): 0.76, 0.92], while criminal legal involvement and healthcare coverage was associated with a lower prevalence of treatment gap among Hispanic and White women only (past year arrest: Hispanic women PR = 0.38, 95% CI: 0.17, 0.86; White women PR = 0.62, 95% CI: 0.47, 0.82).Conclusions: Receipt of treatment is low among women with OUD, especially Black and Hispanic women. Intersectional intervention approaches are needed to increase access and reduce inequities.

Intersectional Stigma as a Fundamental Cause of Health Disparities: A case study of how drug use stigma intersecting with racism and xenophobia creates health inequities for Black and Hispanic persons who use drugs over time

Recent evidence points to racial and ethnic disparities in drug-related deaths and health conditions. Informed by stigma, intersectionality, intersectional stigma, and fundamental cause theories, we aimed to explore whether intersectional stigma was a fundamental cause of health. We document key events and policies over time and find that when progress is made new mechanisms emerge that negatively affect health outcomes for Black and Hispanic persons. We then focus on intersectional stigma targeting Black and Hispanic persons who use drugs. We document that when a person, or group of people, occupy multiple stigmatized identities the processes of stigmatization and scapegoating are particularly persistent and pernicious since people and groups can be stigmatized and scapegoated on varying intersections. We propose that an intersectional stigma framework allows for a better understanding of observed patterns over time, thereby providing a better guide for policies and interventions designed to reduce disparities. As a framework, intersectional stigma aims to recognize that when different sources of stigma collide, a new set of circumstances is created for those who reside in the intersection. We conclude that intersectional stigma is a fundamental cause of health inequities and provide policy recommendations aimed at dismantling intersectional stigma processes and mitigating the effects of intersectional stigmas to ultimately promote better health outcomes for Black and Hispanic persons who use drugs.

Using recovery management checkups for primary care to improve linkage to alcohol and other drug use treatment: a randomized controlled trial three month findings

BACKGROUND AND AIMS

Recovery management checkups (RMC) have established efficacy for linking patients to substance use disorder (SUD) treatment. This study tested whether using RMC in combination with screening, brief intervention, and referral to treatment (SBIRT), versus SBIRT alone, can improve linkage of primary care patients referred to SUD treatment.

DESIGN

A randomized controlled trial of SBIRT as usual (n = 132) versus SBIRT plus recovery management checkups for primary care (RMC-PC) (n = 134) with follow-up assessments at 3 months post-baseline.

SETTING

Four federally qualified health centers in the United States serving low-income populations.

PARTICIPANTS

Primary care patients (n = 266, 64% male, 80% Black, mean age, 48.3 [range, 19-53]) who were referred to SUD treatment after SBIRT.

INTERVENTIONS

SBIRT alone (control condition) compared with SBIRT + RMC-PC (experimental condition).

MEASUREMENT

The primary outcome was any days of SUD treatment in the past 3 months. Key secondary outcomes were days of SUD treatment overall and by level of care, days of alcohol and other drug (AOD) abstinence, and days of using specific substances, all based on self-report.

FINDINGS

At 3-month follow-up, those assigned to SBIRT + RMC-PC (n = 134) had higher odds of receiving any SUD treatment (46% vs 20%; adjusted odds ratio = 4.50 [2.49, 8.48]) compared with SBIRT only, including higher rates of entering residential and intensive outpatient treatment. They also reported more days of treatment (14.45, vs 7.13; d = +0.26), more days abstinent (41.3 vs 31.9; d = +0.22), and fewer days of using alcohol (27.14, vs 36.31; d = -0.25) and cannabis (19.49, vs 28.6; d = -0.20).

CONCLUSIONS

Recovery management checkups in combination with screening, brief intervention, and referral to treatment are an effective strategy for improving linkage of primary care patients in need to substance use disorder treatment over 3 months.

Treatment barriers and gender-based perceptions: Establishing gender-based treatment specialty facilities as a strategy to motivate South African young women to seek treatment for substance use disorders

South Africa alongside other low-middle-income countries have been some of the hardest hit by the substance use scourge. The study sought to identify and measure treatment barriers among young adults (18-29 years) living with substance use disorders, and then examine the role of gender in the perception of treatment barriers, with a view to establish gender-based treatment specialty facilities as a strategy to promote treatment seeking among young South African women. Quantitative method was used for this study, employing simple random sampling. Exploratory factor analysis and independent samples t-tests were used as statistical measures. The identified treatment barriers were found to have a larger effect on females than males. Women were considered less likely to utilise treatment services compared to males. Health promotion practitioners and policymakers can alleviate the situation by establishing gender-based treatment facilities. that respond better to women's needs.

Inclusion and reporting of sex, gender, and race/ethnicity in randomized controlled trials of nonpharmacological treatments for alcohol use disorder: A meta-epidemiologic review

Alcohol use disorders (AUDs) are among the most prevalent behavioral and mental health diagnoses. Individuals with an AUD are at increased risk for numerous consequences across their social, health, and psychological functioning. Research suggests that differences may exist in the prevalence and consequences of AUD and in the efficacy of AUD treatment across demographic characteristics (i.e., sex/gender and race/ethnicity). This meta-epidemiologic review examined the inclusion of diverse groups (sex/gender and race/ethnicity) in published randomized controlled trials of nonpharmacological treatments for AUD since 1994, following passage of the National Institutes of Health Revitalization Act of 1993. We systematically searched databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement criteria. The initial search strategy yielded 7931 articles. After excluding ineligible articles, 155 were included in the present review for synthesis. Of the articles included in this review, only 57 (36.8%) fully reported on both their sample's sex/gender and racial/ethnic breakdown. Of the total sample, seven articles specifically examined one racial/ethnic group and 32 specifically examined one sex/gender group. Six articles (3.9%) reported no information regarding the racial/ethnic breakdown of their sample and five articles (3.2%) reported no information regarding the sex/gender breakdown of their participants. Only two articles (1.3%) reported on subgroup analyses that examined differences in treatment outcomes by both sex/gender and race/ethnicity, despite guidelines set forth by NIH. Only 46 articles (29.7%) described the failure to include diverse sex/gender or racial/ethnic groups or concerns about the generalizability of study findings given their sample's sex/gender or racial/ethnic composition as methodological limitations. These results indicate that substantial efforts must be put forth by the scientific community to ensure the inclusion, analysis, and reporting of data focused on women/females and members of minoritized racial/ethnic groups.

Help-Seeking Patterns and Barriers to Care Among Latino Immigrant Men with Unhealthy Alcohol Use

Latino immigrant men have high rates of unhealthy alcohol use, a wide range of behaviors, from drinking above the recommended limits to severe alcohol use disorder, yet have low levels of treatment-seeking. Little is known about their preferred sources of care and barriers to care. Using survey data from a community-based sample of Latino immigrant men (N=121) with unhealthy alcohol use (AUDIT≥6), we described help-seeking patterns and perceived barriers to care. The mean AUDIT score was 20 (SD 10; range 6-40), and 49% of men had severe levels of unhealthy alcohol use (AUDIT score ≥ 20). We observed low help-seeking rates and high levels of perceived internal and external barriers. Thirty percent reported having sought help for drinking. Most men reported wanting to solve their drinking problem on their own (65%). Our findings were consistent with previous research. Future studies should further describe barriers to treatment among low-income Latino immigrant men with unhealthy alcohol use and identify ways to increase access to low-cost, high-quality treatment options.

Spatial proximity and access to buprenorphine or methadone treatment for opioid use disorder in a sample of people misusing opioids in Southern California

BACKGROUND

In response to the opioid crisis, over the last 10 years substantial strides have been made to increase the availability of evidence-based treatments for opioid use disorder, in particular buprenorphine maintenance, in the United States. Despite these worthwhile efforts, uptake rates of evidence-based treatment remain relatively low. As part of a broader study of opioid misuse, we examined proximity to evidence-based treatment as a potential barrier to treatment access.

METHODS

In 2017-2018, we surveyed 218 individuals misusing prescription opioids or using street opioids in three Southern Californian counties. The study calculated driving distance from place of residence to the closest treatment provider offering buprenorphine or methadone treatment for opioid use disorders.

RESULTS

Median distance to providers was 3.8 km (2.4 miles). Seventy one (33%) participants had received some form of treatment in the last 3 months; however, only 26 (40%) of these had received buprenorphine or methadone maintenance treatment. Participants receiving treatment at the time of their interview were traveling an average 16.8 km (10.4 miles) to reach treatment, indicating that as a group this population was both willing and able to seek and engage with treatment.

CONCLUSIONS

In the suburban and exurban communities in which our study was based, our findings suggest that simple physical proximity to providers of evidence-based treatment for opioid use disorder is no longer a critical barrier. Other barriers to uptake of buprenorphine or methadone maintenance treatment clearly remain and need to be addressed.

DISCLAIMER

Findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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.

Drug and alcohol treatment utilization and barriers among Black, American Indian/Alaskan Native, Latine, Asian/Pacific Islander/Native Hawaiian, and White adults: Findings from NESARC-III

BACKGROUND

Existing epidemiological data suggest differences across racial/ethnic groups in drug and alcohol treatment utilization and barriers to treatment and typically include only Black, Latine, and White adults. The objective of this study was to examine whether disparities remain for DSM-5 lifetime alcohol use disorder (AUD) and drug use disorder (DUD) treatment utilization and barriers across Black, American Indian/Alaska Native (AI/AN), Latine, Asian/Pacific Islander/Native Hawaiian (Asian/PI/NH), and White adults.

METHODS

The current study conducted secondary analyses on data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III). Regression analyses, followed by pairwise comparisons, investigated differences across racial/ethnic groups.

RESULTS

Analyses indicated differences across racial/ethnic groups in AUD treatment utilization. White and AI/AN adults were more likely to utilize a health care professional than were Black adults. Asian/PI/NH and Latine adults were more likely to endorse language as a barrier to AUD treatment than were White adults. Black adults were more likely to use 12-step programs for DUD treatment utilization than were White and Latine adults, and Black and White adults were more likely to use outpatient programs than were Latine adults. Further, Black adults were more likely than Asian/PI/NH and Latine adults to use specialty DUD treatment. AI/AN, Asian/PI/NH, and White adults were more likely to endorse fear of what others would think as a barrier to DUD treatment relative to Black adults. AI/AN adults were more likely to endorse fear of being hospitalized relative to Black, Latine, and White adults. Asian/PI/NH and Latine adults were more likely to indicate that the hours were inconvenient relative to Black and White adults. White adults were more likely to endorse a family member objected relative to Black adults. AI/AN and White adults were more likely to endorse they stopped on their own relative to Black, Asian/PI/NH, and Latine adults. Further, AI/AN and White adults reported the greatest number of barriers to DUD treatment.

CONCLUSIONS

Differences remain across racial/ethnic group in drug and alcohol treatment utilization and barriers to treatment. Future research aimed at increasing treatment utilization across racial/ethnic groups should focus on social determinants of health.

Barriers to retention in substance use treatment: Validation of a new, theory-based scale

PURPOSE

Few studies and no theory-based scales have addressed specific barriers to substance use disorder (SUD) treatment retention. The current study, building on the Theory of Planned Behavior (TPB), sought to (a) identify those barriers that are most strongly associated with treatment retention, and most common, and (b) develop and validate a new scale of retention barriers, focusing on TPB attitude and perceived control components.

METHODS

The study administered surveys to 200 participants initiating SUD treatment at a public, outpatient program in Northern California; the analytic sample (N = 156) included only those not strongly coerced into treatment. Surveys included TPB-based measures of treatment barriers; other motivational readiness measures; treatment coercion and social desirability measures; and clinical severity variables and demographics. Discharge status was collected from program records.

RESULTS

Item and scale analyses identified three dimensions of attitudinal barriers (i.e., Low Perceived Treatment Need/Value, Social Concerns, and Concerns about Missing Substances) and two dimensions of perceived control barriers (i.e., Personal Limitations and Basic Logistic Barriers). Results informed creation of a 19-item Barriers to Retention Scale (BRS) with 5 subscales and very good internal reliability (alpha = 0.88). While all subscale scores were correlated with treatment completion, only Concerns about Missing Substances and total BRS scores predicted treatment completion in multivariate analyses.

CONCLUSIONS

The present study identified core dimensions of treatment retention barriers and developed a new scale predictive of treatment completion and potentially useful as a screener and in future research. Results suggest that interventions to improve retention should focus strongly on concerns about the negative impacts of abstaining from alcohol and drugs on craving and quality of life.

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.

Approaches for Implementing App-Based Digital Treatments for Drug Use Disorders Into Primary Care: A Qualitative, User-Centered Design Study of Patient Perspectives

Background

Digital interventions, such as websites and smartphone apps, can be effective in treating drug use disorders (DUDs). However, their implementation in primary care is hindered, in part, by a lack of knowledge on how patients might like these treatments delivered to them.

Objective

This study aims to increase the understanding of how patients with DUDs prefer to receive app-based treatments to inform the implementation of these treatments in primary care.

Methods

The methods of user-centered design were combined with qualitative research methods to inform the design of workflows for offering app-based treatments in primary care. Adult patients (n=14) with past-year cannabis, stimulant, or opioid use disorder from 5 primary care clinics of Kaiser Permanente Washington in the Seattle area participated in this study. Semistructured interviews were recorded, transcribed, and analyzed using qualitative template analysis. The coding scheme included deductive codes based on interview topics, which primarily focused on workflow design. Inductive codes emerged from the data.

Results

Participants wanted to learn about apps during visits where drug use was discussed and felt that app-related conversations should be incorporated into the existing care whenever possible, as opposed to creating new health care visits to facilitate the use of the app. Nearly all participants preferred receiving clinician support for using apps over using them without support. They desired a trusting, supportive relationship with a clinician who could guide them as they used the app. Participants wanted follow-up support via phone calls or secure messaging because these modes of communication were perceived as a convenient and low burden (eg, no copays or appointment travel).

Conclusions

A user-centered implementation of treatment apps for DUDs in primary care will require health systems to design workflows that account for patients’ needs for structure, support in and outside of visits, and desire for convenience.

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.

Racial Disparities in Substance Use Treatment Completion Among Older Adults

Background and Objectives

Racial disparities in substance use among young adults have been well documented in the substance use literature, but little attention has been paid to older adults. While being an older adult is positively associated with substance use treatment completion, racial disparities in treatment completion have yet to be examined. The purpose of this study was to determine to what extent racial disparities exist in substance use treatment completion among older adults (65 and older).

Research Design and Methods

This cross-sectional study utilized data from the most recent Treatment Episode Data from the Substance Abuse and Mental Health Services Administration, which documents discharges from a publicly funded substance use treatment program in the United States. A total of 17,942 older adults reported to a substance use treatment program in 2017 and 6,653 met the criteria for the study. Chi-squared tests were used to analyze group differences and a binary logistic regression was used to predict substance use treatment completion.

Results

Results show that Black older adults were 37% less likely to complete a substance use treatment program than Whites (OR = 0.630) while Hispanic older adults were 26% more likely to complete a substance use treatment program than Whites (OR = 1.26).

Discussion and Implications

These results support the findings from similar studies with younger adults and support the theory that racial disparities are prevalent across the life span. Although Hispanics had a higher treatment completion rate than Whites, this is likely a reflection of familismo, where decisions about health treatments is a group process and a steady network of family members are available to provide advice and encouragement. The significant disparity observed between Black and White older adults suggest a need to consider cultural, historical, and systemic factors that affect voluntary termination of substance use treatment among Black older adults.

Private health insurance coverage of drug use disorder treatment: 2005-2018

Many privately insured adults with drug use disorders in the United States do not have health care coverage for drug use treatment. The Affordable Care Act sought to redress this gap by including substance use treatments as essential health benefits under new plans offered. This study used data from 11,732 privately insured adult participants of the 2005-2018 National Survey on Drug Use and Health with drug use disorders to examine trends in drug use treatment coverage and the association of coverage with receiving treatment. 37.6% of the participants with drug use disorders did not know whether their plan covered drug use treatment, with little change over time. Among those who knew, coverage increased modestly between the 2005-2013 and 2014-2018 periods (73.5% vs. 77.5%, respectively, p = .015). Coverage was associated with receiving drug use treatment (adjusted odds ratio = 2.09, 95% confidence interval = 1.61-2.72, p < .001). However, even among participants with coverage, only 13.4% received treatment. Broader coverage of drug use treatment could potentially improve treatment rates.

Women's Barriers to Specialty Substance Abuse Treatment: A Qualitative Exploration of Racial/Ethnic Differences

To explore barriers to specialty substance abuse treatment programs among women with recent substance use disorders by race/ethnicity. Qualitative interviews were conducted with 28 women of White, Black, and Latino racial/ethnic descent who reported a substance use disorder in the past 5 years. Interviews were conducted by telephone and were audio-recorded. A codebook was developed using the Theory of Planned Behavior to code and identify barriers within the domains of attitudes, subjective norms, and perceived control toward specialty treatment. Frequencies for coded themes were then compared across all participants and by race/ethnicity. We identified several key differences in barriers to treatment by race/ethnicity. Attitudinal barriers were more pervasive among the narratives of Latinas relative to Black and White women. Latinas were more likely to report not needing treatment and that treatment would not be effective; Latinas were the only group to describe cultural barriers to treatment. Within the subjective norms domain, namely stigma and lack of support, were key barriers. Stigma was more pervasive among the narratives of Latinas and Black women than White women; Latinas were more likely to report a lack of social support for using treatment than both Black and White women. Findings provide deeper insight into barriers that may be contributing to racial/ethnic disparities in the use of substance abuse treatment among women.

Perceived risks and amelioration of harm in research using mobile technology to support antiretroviral therapy adherence in the context of methamphetamine use: a focus group study among minorities living with HIV

BACKGROUND

Methamphetamine use poses a barrier to antiretroviral therapy (ART) adherence. Black and Hispanic men who have sex with men living with HIV (PLWH) shoulder much of the health burden resulting from the methamphetamine and HIV syndemic. Smartphones are nearly ubiquitous in the USA and may be promising vehicles for delivering interventions for ART adherence and drug use cessation. However, the acceptability of using applications to collect sensitive information and deliver feedback in this population has not been adequately explored.

OBJECTIVE

This study examined minority PLWH's appraisals of the risks of participating in smartphone-based research to promote ART adherence in the context of methamphetamine use and explored their views on appropriate steps to mitigate perceived risks of participation.

METHODS

Three focus groups were conducted among Black and Hispanic PLWH who use methamphetamine. Of the 13 participants, 5 had previously participated in a smartphone-based observational study of ART adherence and substance use. Discussants provided feedback on smartphone-based research, including receiving probes for HIV medication adherence, mood, and substance use as well as feedback on passive location-tracking for personalized messages. Transcribed audio-recordings were thematically coded and analyzed using the qualitative software MAXQDA.

RESULTS

Participants expressed confidentiality concerns related to potential unintentional disclosure of their HIV status and methamphetamine use and to possible legal consequences. They additionally expressed concerns around the invasiveness of daily assessments and the potential of methamphetamine use questions to trigger cravings. To mitigate these concerns, they suggested maintaining participant privacy by indirectly asking sensitive questions, focusing on positive behaviors (e.g., number of days sober), allowing user-initiated reporting of location to tailor messages, and ensuring adequate data protections. In addition to financial compensation, participants cited altruism (specifically, continuing a tradition of volunteerism in HIV research) as a motivator for potentially engaging in such research.

CONCLUSIONS

Minority PLWH have concerns regarding the use of smartphones for ART adherence and methamphetamine sobriety intervention research. However, minority PLWH are likely to participate if studies include appropriate protections against risks to confidentiality and experimental harm and are designed to offer future benefit to themselves and other PLWH.

Pretreatment social network characteristics relate to increased risk of dropout and unfavorable outcomes among women in a residential treatment setting for substance use

Increased retention in residential treatment for substance use disorder (SUD) has been associated with more favorable clinical outcomes for residents. Yet SUD treatment dropout remains high. It is essential to uncover factors contributing to these high rates. Little is known about whether features of an individual's social network prior to treatment entry are related to number of days in treatment or to clinical status at treatment termination. To examine these relationships, we analyzed data from 241 women (58.5% Hispanic) entering an SUD residential treatment facility, who agreed to participate in a parent randomized control trial. We assessed characteristics of these women's social networks prior to treatment entry at baseline. We extracted clinician-determined progress at treatment termination and days in treatment two months after treatment entry from clinical records. Data-driven analyses using purposeful selection of predictors showed that the overall size of the social network was associated with increased likelihood of being classified as having achieved good clinical progress in treatment at termination and that number of drug users in the pretreatment social network was related to staying fewer days in treatment. Contrary to our hypothesis, we found no significant associations between other pretreatment social support network characteristics (i.e., social support) and treatment retention or clinical discharge status. Future research should examine how features of social networks change through treatment and how these changes relate to treatment outcomes.

Urban Religious Congregations' Responses to Community Substance Use: An Exploratory Study of Four Cases

Faith-based drug treatment programs are common, and many are implemented through congregations; however, little is documented about how congregations conceptualize and implement these programs. We use case study analysis to explore congregational approaches to drug treatment; qualitative findings emerged in three areas: (1) religion's role in congregational responses to substance use, (2) relationships between program participants and the broader congregation, and (3) interactions between congregational programs and the external community. Congregational approaches to drug treatment can be comprehensive, but work is needed to evaluate such efforts. Congregants' attitudes may influence whether program participants become members of a sustaining congregational community.

Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders

IMPORTANCE

The United States is currently facing an epidemic of deaths related to substance use disorder (SUD), with totals exceeding those due to motor vehicle crashes and gun violence. The epidemic has led to decreased life expectancy in some populations. In recent years, Medicaid eligibility has expanded in some states, and the association of this expansion with SUD-related deaths is yet to be examined.

OBJECTIVE

To examine the association between eligibility thresholds for state Medicaid coverage and SUD-related deaths.

DESIGN, SETTING, AND PARTICIPANTS

Economic evaluation study using a retrospective analysis of state-level data between 2002 and 2015 to determine the association between the Medicaid eligibility threshold and SUD-related deaths, controlling for other relevant policies, state socioeconomic characteristics, fixed effects, and a time trend. Policy variables were lagged by 1 year to allow time for associations to materialize. Data were collected and analyzed from 2016 to 2017.

EXPOSURES

The policy of interest was the state Medicaid eligibility threshold, ie, the highest allowed income that qualifies a person for Medicaid, expressed as a percentage of the federal poverty level. State policies related to mental health, overdose treatment, and law enforcement of drug crimes were included as controls.

MAIN OUTCOMES AND MEASURES

The primary outcome was number of SUD-related deaths, obtained from data provided by the Centers for Disease Control and Prevention.

RESULTS

Across 700 state-year observations, the mean (SD) number of SUD-related deaths was 21.15 (6.05) per 100 000 population. Between 2002 and 2015, the national SUD-related death rate increased from 16.0 to 27.5 per 100 000, while the average Medicaid eligibility threshold increased from 87.2% to 97.1% of the federal poverty level. Over this period, every 100-percentage point increase in the Medicaid eligibility threshold (eg, from 50% to 150% of the federal poverty level) was associated with 1.373 (95% CI, -2.732 to -0.014) fewer SUD-related deaths per 100 000 residents, a reduction of 6.50%. In the 22 states with net contractions in eligibility thresholds between 2005 and 2015, an estimated increase of 570 SUD-related deaths (95% CI, -143 to 1283) occurred. In the 28 states that increased eligibility thresholds, an estimated 1045 SUD-related deaths (95% CI, -209 to 2299) may have been prevented.

CONCLUSIONS AND RELEVANCE

These findings suggest that the overall increase in SUD-related deaths between 2002 and 2015 may have been greater had the average eligibility threshold for Medicaid not increased over this period. Broader eligibility for Medicaid coverage may be one tool to help reduce SUD-related deaths.

Substance abuse treatment in correctional versus non-correctional settings: Analysis of racial/ethnic and gender differences

BACKGROUND

Alcohol and drug abuse are widespread in the US. Substance abuse treatment services are effective, but utilization of services is low, particularly among African Americans, Hispanics, and women. Substance abuse is strongly associated with incarceration, and African Americans and Hispanics make up a disproportionate percentage of individuals with substance abuse problems involved in the criminal justice system. High treatment need, low treatment uptake, and the association between substance abuse and incarceration have led, in part, to correctional institutions filling the treatment gap by increasingly providing safety-net treatment services. We sought to better understand racial/ethnic and gender differences in determinants of treatment location (jail or prison versus non-correctional settings) among treatment-seeking adults.

METHODS

We used repeated cross-sectional data from the National Survey on Drug Use and Health (2002-2016) to identify White, African American, and Hispanic past-year substance abuse treatment participants (n=6,435). We tested the modifying roles of race/ethnicity and gender on the association between several exposure variables and treatment locus using multiple logistic regression.

RESULTS

Ten percent of treatment participants utilized treatment services in a jail or prison, which varied by race/ethnicity (9% of Whites, 15% of African Americans, 12% of Hispanics) and by gender (11% of men, 9% of women). In our fitted models, we found that educational attainment and past-year employment status varied in effect size between African Americans and Whites. The associations for both variables were strongest among African Americans (Any college vs. Less than high school - adjusted Odds Ratio [aOR] = 0.23, 95% Confidence Interval [95% CI] = 0.08, 0.70; Ever unemployed vs. Never unemployed in the past year - aOR = 5.32, 95% CI = 1.94, 14.60). Health insurance status was significantly associated with treatment in a jail or prison only among Whites (Private vs. No insurance - aOR = 0.37, 95% CI = 0.19, 0.69). Co-occurring mental health diagnosis was significant only among African Americans (Any mental health diagnosis vs. none - aOR = 3.91, 95% CI = 1.38, 11.09). Employment and health insurance status were significant only among men (aOR = 2.18, 95% CI = 1.26, 3.77; aOR = 0.39, 95% CI = 0.22, 0.70, respectively).

CONCLUSION

We identified modifying roles for race/ethnicity and gender in the relationship between several factors and treatment utilization in a jail or prison versus non-correctional treatment settings. More numerous factors and stronger effect sizes were identified among African Americans and men in particular. Health promotion interventions promoting the uptake of substance abuse treatment should tailor services to align with the needs of those with the highest risk for incarceration.

Differences in tobacco use prevalence, behaviors, and cessation services by race/ethnicity: A survey of persons in addiction treatment

BACKGROUND

Disparities in tobacco use prevalence, behaviors, and services have been identified among people of different racial and ethnic groups in the United States general population. Persons in addiction treatment have among the highest smoking prevalence of any population. However, little is known about racial and ethnic disparities in tobacco use prevalence, behaviors, and services among persons in addiction treatment.

METHODS

Survey data were used from 1840 clients from 24 addiction treatment programs from the NIDA Clinical Trials Network. Multivariate regression analyses were conducted to assess associations between race/ethnicity (White, African American, Hispanic) and patterns of tobacco and other tobacco product use, as well as quitting behaviors and receipt of tobacco cessation services among current smokers (n = 1425) while in treatment.

RESULTS

There was no difference in cigarette smoking prevalence across racial/ethnic groups. In the multivariate models, Hispanics and African Americans, compared to Whites, were less likely to be daily smokers, use smokeless tobacco, or use e-cigarettes. African Americans and Hispanics reported more past-year quit attempts and higher use of menthol compared to Whites. Hispanics were more interested in quitting while in treatment than Whites. Contrary to expectations, African Americans reported receiving more tobacco cessation advice and services while in treatment than Whites.

CONCLUSIONS

Some findings reflected broader population patterns (e.g., tobacco use behaviors, other tobacco product use), while others did not (e.g., no difference in tobacco use prevalence by race/ethnicity). The reasons for greater receipt of cessation services among African Americans are unclear. Findings indicate the need for continued engagement of African Americans and Hispanics in cessation services while in addiction treatment, and for addressing heavier tobacco use and lack of interest in cessation during treatment among White clients.

Health beliefs associated with poor disease self-management in smokers with asthma and/or COPD: a pilot study

Background: Compared to nonsmokers, smokers with chronic disease are less likely to adhere to self-management recommendations for the management of their chronic conditions. Although the literature notes poor adherence trends in smokers, actual influences of adherence in these patients require further study. This study examines the health beliefs that influence self-management behaviors in smokers with chronic lung disease. Methods: This prospective, cross-sectional study surveyed patients (n = 83) seen in the pulmonary outpatient clinics of the University Medical Center of New Orleans between November 2015 and February 2016. Eligible patients included those between 40-64 years old diagnosed with asthma and/or chronic obstructive pulmonary disease (COPD). Primary measures included perceived beliefs related to the susceptibility to asthma and/or COPD becoming worse, perceived barriers to adherence, and perceived benefits to adherence. Patient characteristics under-study included smoking status, race, gender, and diagnosis. Descriptive and chi-square analyses were performed to characterize the sample. Student's t and and regression analyses were conducted to examine the relationships between perceptions, smoking status, race, gender, and diagnosis. Results: Compared to nonsmokers, smokers perceived their asthma and/or COPD becoming worse (p = 0.0023). Smokers also perceived more barriers (p < 0.0001), and fewer benefits to adherence than nonsmokers (p = 0.0021). Conclusion: The health beliefs of smokers may influence their self-management behaviors. Results of this study can inform the development of services that target smokers in order to improve adherence to self-management behaviors and health outcomes.

Substance use and use disorders and treatment receipt among adults in families receiving Temporary Assistance for Needy Families (TANF), 2003-2014

BACKGROUND/PURPOSE

Legalization of marijuana for medical and/or recreational use in some U.S. states has increased attention to substance use and related problems. However, little attention has been paid to these phenomena among adults in families receiving Temporary Assistance for Needy Families (TANF) whose adverse life experiences may put them at elevated risk of substance use disorders (SUDs).

METHODS

Data from the 2003-2014 National Survey on Drug Use and Health (NSDUH) were used to test trends in past-month binge drinking and past-year marijuana, other illicit drug, and any illicit drug use and to examine SUD prevalence and treatment correlates among adults in TANF families.

RESULTS

While rates of binge drinking and any illicit drug use remained steady, marijuana use increased from 15.8% in 2003/2004 to 21.6% in 2013/2014, a 36.7% increase. Increased marijuana use was strongly related to changes in marijuana risk perception. Among adults in TANF families, 19.5% of men and 10.8% of women had a past-year SUD, but only one in five received treatment. Those aged 18-25, Black or Hispanic women, and those who had children at home when surveyed were less likely to have received treatment.

DISCUSSION

Preventive efforts to address substance use, especially marijuana use, among adults in TANF families are needed. Moreover, given greater odds of unmet SUD treatment need among these economically disadvantaged adults, particularly racial/ethnic minority women and those who are in emerging adulthood, uninsured, and have children at home, measures to provide more inclusive services such as integrated behavioral health care are needed.

Understanding barriers to specialty substance abuse treatment among Latinos

BACKGROUND

National studies have documented that Latinos are less likely to use specialty substance abuse treatment (e.g., rehabilitation programs, in/out-patient services) than other racial/ethnic groups. Disparities in treatment utilization are particularly pronounced between Latinos and Whites. Few national studies have explicitly examined barriers to treatment by race/ethnicity, and current results are inconclusive. The purpose of this study was to gain a better understanding of barriers to specialty substance abuse treatment among Latinos.

METHODS

In 2017-2018, in-depth qualitative interviews were conducted with 54 White, Black, and Latino participants who met eligibility criteria for a recent substance use disorder. Participants were recruited via online ads and screened for eligibility through an online survey. Interview questions were grounded in the Theory of Planned Behavior (TBP): Participants were asked about treatment-related barriers in the domains of attitudes, subjective norms, and perceived control. Interviews were transcribed verbatim and coded by two independent coders. Barriers were compared across all interviews and by race/ethnicity.

RESULTS

Latinos were significantly more likely to report attitudinal and subjective norm barriers than their White and Black counterparts. Within the attitudes domain, results suggested that Latinos largely avoided specialty treatment due to barriers stemming from cultural factors, perceived treatment efficacy, recovery goals, and perceived treatment need. In the area of subjective norms, stigma and perceived lack of social support from family were more pervasive among Latinos' narratives. Lastly, in terms of perceived control, a minority of Latinos reported logistical barriers to treatment.

CONCLUSION

Specialty substance abuse treatment services have been found to be effective regardless of race/ethnicity. Understanding why Latinos use specialty treatment at low rates is key to reducing existing racial/ethnic disparities related to substance abuse. This study identified several malleable barriers that interventions can target to increase Latinos' utilization of treatment. These barriers may also be key to explaining Latino-White disparities in treatment utilization.

Optimizing a community-engaged multi-level group intervention to reduce substance use: an application of the multiphase optimization strategy

BACKGROUND

Rates of alcohol and illicit drug use (AIDU) are consistently similar across racial groups (Windsor and Negi, J Addict Dis 28:258-68, 2009; Keyes et al. Soc Sci Med 124:132-41, 2015). Yet AIDU has significantly higher consequences for residents in distressed communities with concentrations of African Americans (DCAA - i.e., localities with high rates of poverty and crime) who also have considerably less access to effective treatment of substance use disorders (SUD). This project is optimizing Community Wise, an innovative multi-level behavioral-health intervention created in partnership with service providers and residents of distressed communities with histories of SUD and incarceration, to reduce health inequalities related to AIDU.

METHODS

Grounded in critical consciousness theory, community-based participatory research principles (CBPR), and the multiphase optimization strategy (MOST), this study employs a 2 × 2 × 2 × 2 factorial design to engineer the most efficient, effective, and scalable version of Community Wise that can be delivered for US$250 per person or less. This study is fully powered to detect change in AIDU in a sample of 528 men with a histories of SUD and incarceration, residing in Newark, NJ in the United States. A community collaborative board oversees recruitment using a variety of strategies including indigenous field worker sampling, facility-based sampling, community advertisement through fliers, and street outreach. Participants are randomly assigned to one of 16 conditions that include a combination of the following candidate intervention components: peer or licensed facilitator, group dialogue, personal goal development, and community organizing. All participants receive a core critical-thinking component. Data are collected at baseline plus five post-baseline monthly follow ups. Once the optimized Community Wise intervention is identified, it will be evaluated against an existing standard of care in a future randomized clinical trial.

DISCUSSION

This paper describes the protocol of the first ever study using CBPR and MOST to optimize a substance use intervention targeting a marginalized population. Data from this study will culminate in an optimized Community Wise manual; enhanced methodological strategies to develop multi-component scalable interventions using MOST and CBPR; and a better understanding of the application of critical consciousness theory to the field of health inequalities related to AIDU.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02951455 . Registered on 1 November 2016.

Roman Catholic Priests as Referral Sources and Treatment Aides for Hispanics with Substance Misuse/Abuse Problems

This self-administered mail survey study, conducted along the USA-Mexico border, examines Roman Catholic Priests' involvement in aiding Hispanic individuals with substance abuse problems. The Priests were found to be highly involved or willing to be involved in: (1) participating in juramentos (pledge usually to Virgin of Guadalupe, with Priest as witness, to temporarily abstain from substance use), (2) providing referrals, and (3) working with family and/or treatment resources in the community in order to help the person seeking their help. Fluency in Spanish, regardless of Hispanic ethnicity, was found to positively impact involvement in juramentos, providing referrals, and willingness to work with community resources.

A pilot trial of text-delivered peer network counseling to treat young adults with cannabis use disorder

Approximately 1.8 million young adults aged 18 to 25 had a Cannabis Use Disorder (CUD) in the past year. Unfortunately, engaging young adults in treatment is very challenging. Creative approaches to treat cannabis disorders such as integrating mobile technology with evidence-based treatments are warranted. In light of these challenges, we developed a text message-delivered version of Peer Network Counseling (PNC-txt), which is a substance use intervention that focuses on peer relations. PNC-txt engages participants in 16 automated, personalized text interactions over 4weeks. We conducted a randomized controlled trial to test the efficacy of PNC-txt against a waitlist control group with 30 treatment seeking young adults (ages 18-25) who met DSM-5 criteria for CUD. Self-report and urine analyses were used to test outcomes at the three-month follow-up. The PNC-txt group significantly reduced their cannabis use related problems as well as cannabis cravings, compared to the control group. PNC-txt participants also had a significantly greater percentage with urines negative for cannabis metabolites compared to controls. Moderation analysis showed that CUD severity level moderated treatment, suggesting that PNC-txt is more effective for participants with medium and high levels of CUD severity. All effect sizes ranged from medium to large. Results from this pilot trial are promising and warrant further research on PNC-txt for addressing cannabis use disorder.

Gender and ethnic differences in primary care patients' response to computerized vs. in-person brief intervention for illicit drug misuse

This study is a secondary analysis from a randomized clinical trial of computerized vs. in-person brief intervention (BI) for illicit drug misuse among adult primary care patients (N=359; 45% Female; 47% Hispanic) with moderate-risk illicit drug misuse as measured by the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). This study examined differences in response to the two brief intervention strategies (both based on motivational interviewing) on the basis of gender and ethnicity, comparing non-Hispanic males, non-Hispanic females, Hispanic males, and Hispanic females. Participants were assessed at baseline, 3-, 6-, and 12-month follow-up with the ASSIST. Trajectories in Global Continuum of Illicit Drug Risk Scores were examined using a generalized linear mixed model. There were significant differences in response to computerized vs. in-person BI over time on the basis of gender-ethnic subgroups (Gender×Ethnicity×Condition×Time interaction; p=0.03), with Hispanic males tending to respond more favorably to the computerized BI and Hispanic females tending to respond more favorably to the in-person BI. There was no clear differentiation in response to the two BIs among non-Hispanic males, while among non-Hispanic females the pattern of change converged following baseline differences. Consideration of gender and ethnic differences in future studies of BI is warranted.

Predictors of treatment utilization and barriers to treatment utilization among individuals with lifetime cannabis use disorder in the United States

OBJECTIVE

To present information on predictors of treatment utilization and barriers to treatment utilization among individuals with lifetime DSM-5 cannabis use disorder (CUD).

METHOD

Face-to-face survey of a representative sample of the adult US general population (n=36,309).

RESULTS

Treatment rates for CUD were low in this general population survey (13.7%). Severity of CUD and comorbidity of other lifetime drug use disorders were significant predictors of lifetime treatment utilization for CUD. Preference for self-reliance, minimizing problems, fear of stigma, and financial and structural issues were among the most frequently endorsed reasons for respondents not seeking treatment when they perceived the need for treatment among individuals with lifetime CUD, regardless of whether they eventually utilized treatment at some time in their lives.

CONCLUSIONS

Given the rising prevalence of CUD in the US over the past decade and currently low treatment rates for CUD, increased provision for services for CUD appears critically needed, especially those that screen for and treat, when present, other drug use disorders. Programs to reduce stigma and financial barriers are needed, as well as programs to increase awareness among the general public, health care professionals about the nature and seriousness of CUD, and the availability and effectiveness of treatment for this disorder.

Wanting and Getting Help for Substance Problems on Both Sides of the US-Mexico Border

The US-Mexico border presents potential cultural and logistic barriers to obtaining substance abuse treatment. We compare the prevalence and correlates of wanting and getting help between border and non-border residents in both the US and Mexico. Data come from the 2011 to 2012 US-Mexico Study on Alcohol and Related Conditions which surveyed 3214 border and 1582 non-border residents in the US and Mexico. Multivariate logistic regressions estimate the effect of border residence on desire for and receipt of help. In both countries, border substance users were about half as likely as nonborder substance users to have wanted or obtained any kind of help, independent of predisposing, need and enabling factors, including migration status. Among those desiring help, however, about half had obtained it, both on and off the border in both countries. While substantial proportions of those who need help do not get it either on or off the border, lower motivation for treatment may be more important than access in explaining border/non-border differences. Future research should investigate whether there are border-specific barriers to wanting help, and how to minimize them.

Initiation of Addiction Treatment and Access to Services: Young Adults' Accounts of Their Help-Seeking Experiences

Substance addiction in young adults is particularly problematic. Yet, much remain at stake in understanding the specifics of this population's access to services. The objective of this study is to explore young adults' initiation of substance misuse treatment. Our study sample was composed of 35 individuals aged 18 to 30 with problematic psychoactive substance use who have been identified in criminal courts, hospital emergency departments, and Health and Social Services Centers in Québec (Canada). A thematic analysis was performed on the 62 semi-structured interviews conducted with participants. Three components emerged. First, personal elements-expectations, individual motivations, perceptions of use, and capacity to control it-influence initiation of substance misuse treatment. Second, family and peers have noticeable influences. Finally, system characteristics and prior care experiences also shape the process. Consideration should be given to tailor interventions that can reach young adults and encourage them to initiate appropriate care.

The daily progress system: A proof of concept pilot study of a recovery support technology tool for outpatient substance abuse treatment

BACKGROUND

Illicit substance use remains highly prevalent in the US, and epidemiological surveillance surveys estimate that in 2015, over 27 million individuals (10.1% of the US population) 12 years of age or older used illicit drugs in the past 30 days.¹ Outpatient treatment delivered in community-based settings is the dominant modality for addiction treatment, typically involving weekly psychosocial counseling sessions in an individual and/or group format.^2,3 Unfortunately, relapse and premature treatment discontinuation are quite common in outpatient treatment.^3-5 Objectives: This is a pilot proof of concept feasibility study involving clients presenting for outpatient SUD treatment. This study sought to examine the feasibility and acceptability of the Daily Progress System (DPS), a telephone-based software program, using interactive voice response (IVR), designed to enhance quality care and improve client outcomes.

METHODS

Individuals who presented at the participating treatment clinic, who met study eligibility criteria, and who provided written informed consent to participate were included in the study (N = 15; 53.3% females). Incentives were paid to participants for calls completed.

RESULTS

Participants completed 65% of scheduled daily call-ins, representing 273 person-days of data on client cravings, mood, substance use, and involvement in recovery support activities. The average call duration was approximately 2 minutes and 42 seconds. There was a high degree of client and counselor acceptance and satisfaction using the system. Conclusions and Clinical Significance: Findings suggest that the DPS appears to be a feasible means of potentially addressing relapse and treatment engagement issues based on client and counselor engagement and satisfaction with the system.

Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA)

In 2016, the International Network on Brief Interventions for Alcohol & Other Drugs convened a meeting titled “Rethinking alcohol interventions in health care”. The aims of the meeting were to synthesize recent evidence about screening and brief intervention and to set directions for research, practice, and policy in light of this evidence. Screening and brief intervention is efficacious in reducing self-reported alcohol consumption for some with unhealthy alcohol use, but there are gaps in evidence for its effectiveness. Because screening and brief intervention is not known to be efficacious for individuals with more severe unhealthy alcohol use, recent data showing the lack of evidence for referral to treatment as part of screening and brief intervention are alarming. While screening and brief intervention was designed to be a population-based approach, its reach is limited. Implementation in real world care also remains a challenge. This report summarizes practice, research, and policy recommendations and key research developments from our meeting. In order to move the field forward, a research agenda was proposed to (1) address evidence gaps in screening, brief intervention, and referral to treatment, (2) develop innovations to address severe unhealthy alcohol use within primary care, (3) describe the stigma of unhealthy alcohol use, which obstructs progress in prevention and treatment, (4) reconsider existing conceptualizations of unhealthy alcohol use that may influence health care, and (5) identify efforts needed to improve the capacity for addressing unhealthy alcohol consumption in all world regions.

Asian American and Pacific Islander substance use treatment admission trends

BACKGROUND

A national analysis of Asian Americans and Pacific Islanders (AAPI) substance use treatment admissions has yet to be studied. We sought to explore admission trends for AAPI, demographic and treatment variable change, and individual state admission change over time.

METHODS

We used retrospective time-series logistic regression treating year as a predictor of yearly treatment admission trends, between-state test for heterogeneity of treatment effects among states' AAPI admissions, and percent-changes of AAPI demographic and treatment characteristics. Participants included AAPI (n=135,356) and comparison non-AAPI (n=8,938,982) treatment groups' first-time admissions (N=9,074,338) in United States treatment centers receiving public funding from 2000 to 2012.

RESULTS

AAPI demonstrated a greater increase in admissions than non-AAPI from 2000 to 2012 (p<0.0001; OR=1.02, 95% CI=1.019-1.022). Large percent increases were demonstrated in multiple demographic and treatment characteristic, most notably in prescription opioids as a problem substance, age of first use for the oldest and youngest groups, and homelessness. In addition, trends are provided for individual states to help prioritize resource need.

CONCLUSIONS

The present demographic and treatment characteristics revealed specific variables that may help to improve a culturally competent understanding of increasing risk factors among AAPI clients. The present findings may help to demonstrate which states may need to increase AAPI-specific resources and interventions.

Influence of gender and race/ethnicity on perceived barriers to help-seeking for alcohol or drug problems

This study examines reasons why people do not seek help for alcohol or drug problems by gender and race/ethnicity using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey. Multivariate models were fit for 3 barriers to seeking help (structural, attitudinal, and readiness for change) for either alcohol or drug problems, controlling for socio-demographic characteristics and problem severity. Predicted probabilities were generated to evaluate gender differences by racial/ethnic subgroups. Over three quarters of the samples endorsed attitudinal barriers related to either alcohol or drug use. Generally, women were less likely to endorse attitudinal barriers for alcohol problems. African Americans and Latina/os were less likely than Whites to endorse attitudinal barriers for alcohol problems, Latina/os were less likely than Whites to endorse readiness for change barriers for alcohol and drug problems, however, African Americans were more likely to endorse structural barriers for alcohol problems. Comparisons within racial/ethnic subgroups by gender revealed more complex findings, although across all racial/ethnic groups women endorsed attitudinal barriers for alcohol problems more than men. Study findings suggest the need to tailor interventions to increase access to help for alcohol and drug problems that take into consideration both attitudinal and structural barriers and how these vary across groups.

Failure to get into substance abuse treatment

Among substance abusers in the US, the discrepancy in the number who access substance abuse treatment and the number who need treatment is sizable. This results in a major public health problem of access to treatment. The purpose of this study was to examine characteristics of Persons Who Use Drugs (PWUDs) that either hinder or facilitate access to treatment. 2646 participants were administered the Risk Behavior Assessment (RBA) and the Barratt Impulsiveness Scale. The RBA included the dependent variable which was responses to the question "During the last year, have you ever tried, but been unable, to get into a drug treatment or detox program?" In multivariate analysis, factors associated with being unable to access treatment included: Previously been in drug treatment (OR=4.51), number of days taken amphetamines in the last 30days (OR=1.18), traded sex for drugs (OR=1.53), homeless (OR=1.73), Nonplanning subscale of the Barratt Impulsiveness Scale (OR=1.19), age at interview (OR=0.91), and sexual orientation, with bisexual men and women significantly more likely than heterosexuals to have tried but been unable to get into treatment. The answers to the question on "why were you unable to get into treatment" included: No room, waiting list; not enough money, did not qualify, got appointment but no follow through, still using drugs, and went to jail before program start. As expected, findings suggest that limiting organizational and financial obstacles to treatment may go a long way in increasing drug abuse treatment accessibility to individuals in need. Additionally, our study points to the importance of developing approaches for increasing personal planning skills/reducing Nonplanning impulsivity among PWUDs when they are in treatment as a key strategy to ensure access to additional substance abuse treatment in the future.

Patient, Program, and System Barriers and Facilitators to Detoxification Services in the U.S. Veterans Health Administration: A Qualitative Study of Provider Perspectives

BACKGROUND

Because substance use disorder (SUD) treatment is expanding, and detoxification (detox) is often the entry point to SUD treatment, it is critical to provide ready access to detox services.

OBJECTIVES

The purpose of the current study was to examine patient, program, and system barriers or facilitators to detox access within an integrated health care system with variable rates of detox utilization across facilities.

METHODS

Inpatient and outpatient providers from 31 different U.S. Veterans Health Administration detox programs were interviewed.

RESULTS

Qualitative analyses identified six facilitators and 11 barriers to detox access. Facilitators included program staff and program characteristics such as encouragement and immediate access, as well as systemic cooperation and patient circumstances. Barriers to detox included programmatic and systemic problems, including lack of available detox services, program rules or admission requirements, funding shortages, stigma related to a SUD diagnosis or receiving detox services, and a deficiency of education and training. Other major barriers pertained to patients' lack of motivation and competing responsibilities.

CONCLUSIONS/IMPORTANCE

To improve detox access, health care settings should consider enhancing supportive relationships by emphasizing outreach, engagement, and rapport-building with patients, improving systemic communication and teamwork, educating patients on available detox services and the detox process, and addressing patient centered barriers such as resistance to detox or competing responsibilities. In addition, programs should consider open-door and immediate-admission policies. These approaches may improve detox access, which is important for increasing the likelihood of transitioning patients to SUD treatment, thus improving outcomes and reducing utilization of high-cost services.

Adapting Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs to Culturally Diverse Clinical Populations

OBJECTIVES

To review the literature on the screening, brief intervention, and referral to treatment (SBIRT) approach to alcohol and drug use with racial and ethnic subgroups in the United States and to develop recommendations for culturally competent SBIRT practice.

METHODS

Articles reporting on the use of SBIRT components (screening, brief intervention, referral to treatment) for alcohol and drug use were identified through a comprehensive literature search of PubMed from 1995 to 2015.

RESULTS

A synthesis of the published literature on racial and ethnic considerations regarding SBIRT components (including motivational interviewing techniques) was created using evidence-based findings. Recommendations on culturally competent use of SBIRT with specific ethnic groups are also described.

CONCLUSIONS

On the basis of the literature reviewed, SBIRT offers a useful set of tools to help reduce risky or problematic substance use. Special attention to validated screeners, appropriate use of language/literacy, trust building, and incorporation of patient and community health care preferences may enhance SBIRT acceptability and effectiveness.

PRACTICE IMPLICATIONS

Providers should consider the implications of previous research when adapting SBIRT for diverse populations, and use validated screening and brief intervention methods. The accompanying case illustration provides additional information relevant to clinical practice.

Psychosocial Factors Associated with Substance Abuse and Anxiety on Immigrant and U.S. Born Latinos

Latinos are exposed to adverse psychosocial factors that impact their health outcomes. Given the heterogeneity and rapid growth of this population, there is an urgent need to understand the mechanisms through which psychosocial factors impact substance abuse and anxiety between immigrant and U.S. born Latino adults. The present study employs a multi-group path analysis using Mplus 7.2 to examine generational differences in the paths between affiliation culture, years of formal education, contact with important people, and length of full-time employment to substance abuse and anxiety in immigrant and U.S. born Latino adults who completed substance abuse treatment. A total of 131 participants (Mage= 36.3, SD ± 10.5, 86.3% males, 48.1% non-U.S. born with a mean length of stay of 19 years in the U.S. (SD ± 13.71) in recovery from substance abuse completed self-report measures. Results from the multi-group path analysis suggest that being more affiliated to the U.S. culture is associated with substance abuse, whereas years of formal education and longer full-time employment is associated with reduced anxiety in the immigrant group. Conversely, frequent contact with important people and affiliation to the U.S. culture are associated with fewer years of substance abuse, whereas longer full-time employment is associated with substance abuse in the U.S. born group. Anxiety and substance abuse was correlated only in the U.S. born group. The implications of these findings are discussed.

The Role of Social Capital in African Americans' Attempts to Reduce and Quit Cocaine Use

BACKGROUND

Research examining substance users' recovery has focused on individual-level outcomes while paying limited attention to the contexts within which individuals are embedded, and the social processes involved in recovery.

OBJECTIVES

This paper examines factors underlying African American cocaine users' decisions to reduce or quit cocaine use and uses practice theory to understand how lifestyle changes and shifts in social networks facilitate access to the capital needed to change cocaine use patterns.

METHODS

The study, an in-depth analysis of substance-use life history interviews carried out from 2010 to 2012, included 51 currently not-in-treatment African American cocaine users in the Arkansas Mississippi Delta region. A blended inductive and deductive approach to data analysis was used to examine the socio-cultural and economic processes shaping cocaine use and recovery.

RESULTS

The majority of participants reported at least one lifetime attempt to reduce or quit cocaine use; motivations to reduce use or quit included desires to meet social role expectations, being tired of using, and incarceration. Abstinence-supporting networks, participation in conventional activities, and religious and spiritual practices afforded access to capital, facilitating cocaine use reduction and sobriety.

CONCLUSIONS

Interventions designed to increase connection to and support from nondrug using family and friends with access to recovery capital (e.g., employment, faith community, and education) might be ideal methods to reduce substance use among minorities in low-income, resource-poor communities.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings

PURPOSE

The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking.

METHOD

NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized.

RESULT

The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers.

CONCLUSIONS

Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.

Technology-based interventions for tobacco and other drug use in university and college students: a systematic review and meta-analysis

Background

University students have high levels of tobacco and other drug use, yet they are unlikely to seek traditional care. Technology-based interventions are highly relevant to this population. This paper comprises a systematic review and meta-analysis of published randomized trials of technology-based interventions evaluated in a tertiary (university/college) setting for tobacco and other drug use (excluding alcohol). It extends previous reviews by using a broad definition of technology.

Methods

PubMed, PsycInfo, and the Cochrane databases were searched using keywords, phrases, and MeSH terms. Retrieved abstracts (n = 627) were double screened and coded. Included studies met the following criteria: (1) the study was a randomized trial or a randomized controlled trial (RCT); (2) the sample was composed of students attending a tertiary (e.g., university, college) institution; (3) the intervention was either delivered by or accessed using a technological device or process (e.g., computer/internet, telephone, mobile short message services [SMS]); (4) the age range or mean of the sample was between 18 and 25 years; and (5) the intervention was designed to alter a drug use outcome relating to tobacco or other drugs (excluding alcohol).

Results

A total of 12 papers met inclusion criteria for the current review. The majority of included papers examined tobacco use (n = 9; 75%), two studies targeted marijuana use (17%); and one targeted stress, marijuana, alcohol, and tobacco use. A quantitative meta-analysis was conducted on the tobacco use studies using an abstinence outcome measure (n = 6), demonstrating that the interventions increased the rate of abstinence by 1.5 times that of controls (Risk Ratio [RR] = 1.54; 95% Confidence Interval [CI] = 1.20–1.98). Across all 12 studies, a total of 20 technology-based interventions were reviewed. A range of technology was employed in the interventions, including stand-alone computer programs (n = 10), internet (n = 5), telephone (n = 3), and mobile SMS (n = 2).

Conclusions

Although technological interventions have the potential to reduce drug use in tertiary students, very few trials have been conducted, particularly for substances other than tobacco. However, the improvement shown in abstinence from tobacco use has the potential to impact substantially on morbidity and mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s13722-015-0027-4) contains supplementary material, which is available to authorized users.

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