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

Workforce Diversity and disparities in wait time and retention among opioid treatment programs

BACKGROUND

Workforce diversity is a key strategy to improve treatment engagement among members of racial and ethnic minority groups. In this study, we seek to determine whether workforce diversity plays a role in reducing racial and ethnic differences in wait time to treatment entry and retention in different types of opioid use disorder treatment programs.

METHODS

We conducted comparative and predictive analysis in a subsample of outpatient opioid treatment programs (OTPs), who completed access and retention survey questions in four waves of the National Drug Abuse Treatment System Survey (162 OTPs in 2000, 173 OTPs in 2005, 282 OTPs in 2014, and 300 OTPs in 2017). We sought to assess the associations between workforce diversity on wait time and retention, accounting for the role of Medicaid expansion and the moderating role of program ownership type (i.e., public, non-profit, for-profit) among OTPs located across the United States.

RESULTS

We found significant differences in wait time to treatment entry and retention in treatment across waves. Average number of waiting days decreased in 2014 and 2017; post Medicaid expansion per the Affordable Care Act, while retention rates varied across years. Key findings show that programs with high diversity, measured by higher percent of African American staff and a higher percent of African American clients, were associated with longer wait times to enter treatment, compared to low diversity programs. Programs with higher percent of Latino staff and a higher percent of Latino clients were associated with lower retention in treatment compared with low diversity programs. However, program ownership type (public, non-profit and for-profit) played a moderating role. Public programs with higher percent of African American staff were associated with lower wait time, while non-profit programs with higher percent of Latino staff were related to higher retention.

CONCLUSIONS

Findings show decreases in wait time over the years with significant variation in retention during the same period. Concordance in high workforce and client diversity was associated with higher wait time and lower retention. But these relations inverted (low wait time and high retention) in public and non-profit programs with high staff diversity. Findings have implications for building resources and service capacity among OTPs that serve a higher proportion of minority clients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objective

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

Data source

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

Study design

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

Data collection

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

Principal findings

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

Conclusions

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

A qualitative investigation of addiction counselors' perceptions and experiences implementing an open-access model for treating opioid use disorder

OBJECTIVE

To examine addiction counselors' perceptions and experiences of implementing an open-access model for methadone maintenance treatment (MMT), in which the program rapidly enrolled prospective patients, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Between 2006, when the treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the study site grew from 1431 to 4500.

METHODS

Participants were 31 addiction counselors employed at a treatment organization that implemented an open-access model to scale up MMT. We examined counselors' perceptions and experiences of working in programs that employed this model, using individual semi-structured interviews, which an interdisciplinary team audiotaped, transcribed, and systematically coded using grounded theory. The team reviewed themes and reconciled disagreements (rater agreement was 98%). We describe themes that more than 10% of participants reported.

RESULTS

Counselors described perceived advantages of the open-access model for clients (e.g., "individualized to client needs"), clinicians (e.g., "fewer demands"), and the community (e.g., "crime reduced"). Counselors also described perceived disadvantages of the open-access model for clinicians (e.g., "uneven workload") and clients (e.g., "need for more intensive services for some clients"), as well as program-level concerns (e.g., "perceived lack of structure").

CONCLUSIONS

Counselors who work in opioid treatment programs that use an open-access framework described multiple benefits to themselves, their clients, and the public; they also outlined disadvantages for themselves and clients, which research should further explore and address to facilitate MMT scale up.

Assessing public behavioral health services data: a mixed method analysis

Background

Measuring behavioral health treatment accessibility requires timely, comprehensive and accurate data collection. Existing public sources of data have inconsistent metrics, delayed times to publication and do not measure all factors related to accessibility. This study seeks to capture this additional information and determine its importance for informing accessibility and care coordination.

Methods

The 2018 National Survey for Substance Abuse and Treatment Services (N-SSATS) data were used to identify behavioral health facilities in Indiana and gather baseline information. A telephone survey was administered to facilities with questions parallel to the N-SSATS and additional questions regarding capacity and patient intake. Quantitative analysis includes chi-square tests. A standard qualitative analysis was used for theming answers to open-ended questions.

Results

About 20% of behavioral health facilities responded to the study survey, and non-response bias was identified by geographic region. Among respondents, statistically significant differences were found in several questions asked in both the study survey and N-SSATS. Data gathered from the additional questions revealed many facilities to have wait times to intake longer than 2 weeks, inconsistency in intake assessment tools used, limited capacity for walk-ins and numerous requirements for engaging in treatment.

Conclusion

Despite the low response rate to this study survey, results demonstrate that multiple factors not currently captured in public data sources can influence coordination of care. The questions included in this study survey could serve as a framework for routinely gathering these data and can facilitate efforts for successful coordination of care and clinical decision-making.

Characteristics and current clinical practices of opioid treatment programs in the United States

BACKGROUND

Given rising rates of opioid use disorder (OUD) and related consequences, opioid treatment programs (OTPs) can play a pivotal role in the U.S. opioid crisis. There is a paucity of recent research to guide how best to leverage OTPs in the opioid response.

METHODS

We conducted a national survey of U.S. OTPs using a 46-question electronic survey instrument covering three domains: 1) OTP characteristics; 2) services offered; and 3) current clinical practices. Descriptive statistics and multivariable logistic regression examined variables in these domains.

RESULTS

Among responding OTPs, 32.4% reported using all three medications for OUD treatment; 95.8% used methadone, 61.8% used buprenorphine, and 43.9% used naltrexone. The mean (SD) number of patients currently receiving methadone was 383 (20.4), buprenorphine 51 (7.0), extended-release naltrexone 6 (1.0). Viral hepatitis testing was provided by 60.9% of OTPs, 15.3% provided hepatitis B vaccination, 14.9% provided hepatitis A vaccination, and 12.6% provided medication treatment for hepatitis C virus infection. HIV testing was provided by 60.7% of OTPs, 9.5% provided pre-exposure prophylaxis, and 8.4% provided medication treatment for HIV. OTP characteristics associated with using all three forms of medications for OUD included: providing medication for alcohol use disorder (aOR = 5.24, 95% CI:2.99-9.16), providing telemedicine services (aOR = 3.82, 95% CI:2.14-6.84), and directly providing naloxone to patients (aOR = 2.57, 95% CI:1.53-4.29). Multiple barriers to providing buprenorphine and extended-release naltrexone were identified.

CONCLUSIONS

Efforts are needed to increase availability of all medications approved to treat OUD in OTPs, integrate infectious disease-related services, and expand the reach of OTPs in the U.S.

Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and drug treatment initiation and engagement among people living with the human immunodeficiency virus (HIV) and patients without an HIV diagnosis

Background:

Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis.

Methods:

Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models.

Results:

There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement.

Conclusions:

AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV.

An investigation of an open-access model for scaling up methadone maintenance treatment

AIMS

To examine retrospectively patient and programmatic outcomes following the development and implementation of an 'open-access' model in which prospective patients were enrolled rapidly in methadone maintenance treatment, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options.

DESIGN

Medical and administrative records were abstracted to compare data for 1 year before and 9 years after initiating the implementation of an open-access treatment model in May 2007.

SETTING

Methadone maintenance treatment center in Connecticut, USA.

PARTICIPANTS

Individuals with opioid use disorder entering treatment between July 2006 and June 2015. In June 2015, 64% (n = 2594) of the sample were men and 80% (n = 3133) reported that they were white.

INTERVENTION

The Network for the Improvement of Addiction Treatment-informed open-access treatment model uses process improvement strategies to improve treatment access and capacity.

MEASUREMENTS

Census, waiting time, retention, non-medical opioid use, patient mortality and financial sustainability (net income and state-block grants as proportions of revenue).

FINDINGS

In the 9 years following the initial implementation of the open-access model, patient census increased by 183% from 1431 to 4051, and average waiting-time days decreased from 21 to 0.3 (same day) without apparent deleterious effects on rates of retention, non-medical opioid use or mortality. Between fiscal years (FY) 06 and FY 15, net operating margin rose from 2 to 10%, while state-block grant revenues declined 14% and the proportion of total revenue from state-block grant revenue decreased from 49 to 24%.

CONCLUSIONS

An open-access model for rapid enrolment of people with opioid use disorder in methadone treatment appears to improve treatment access, capacity, and financial sustainability without evidence of deleterious effects on treatment outcomes.

A population-based examination of trends and disparities in medication treatment for opioid use disorders among Medicaid enrollees

BACKGROUND

Medication treatment (MT) with methadone and buprenorphine are effective treatments for opioid use disorders, but little information is available regarding the extent to which buprenorphine's approval resulted in more individuals receiving MT nor to what extent receipt of such treatment was equitable across communities.

METHODS

To examine changes in MT utilization and the association between MT utilization and county-level indicators of poverty, race/ethnicity, and urbanicity, we used Medicaid claims of non-dually eligible Medicaid enrollees aged 18-64 from 14 states for 2002-2009. We generated county-level aggregate counts of MT (methadone, buprenorphine, and any MT) by year (N = 7760 county-years). We estimated count data models to identify associations between MT and county characteristics, including levels of poverty and racial/ethnic concentration.

RESULTS

The number of Medicaid enrollees receiving MT increased 62% from 2002 to 2009. The number of enrollees receiving methadone increased 20%, with the remaining increase resulting from buprenorphine. Urban county residents were significantly more likely to receive MT in both 2002 and 2009 than rural county residents. However, buprenorphine substantially increased MT in rural counties from 2002 to 2009. Receipt of MT increased at a much higher rate for residents of counties with lower poverty rates and lower concentrations of black and Hispanic individuals than for residents of counties without those characteristics.

CONCLUSIONS

The increase in Medicaid enrollees receiving MT in the years following buprenorphine's approval is encouraging. However, it is concerning that MT trends varied so dramatically by characteristics of the county population and that increases in utilization were substantially lower in counties with populations that historically have been disadvantaged with respect to health care access and quality. Concerted efforts are needed to ensure that MT benefits are equitably distributed across society and reach disadvantaged individuals who may be at higher risk of experiencing opioid use disorders.

Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study

OBJECTIVE

To assess the relationship of restrictions on Medicaid benefits for addiction treatment to Medicaid acceptance among addiction treatment programs.

DATA SOURCES

We collected primary data from the 2013-2014 wave of the National Drug Abuse Treatment System Survey.

STUDY DESIGN

We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs.

DATA COLLECTION

Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine.

PRINCIPAL FINDINGS

Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states.

CONCLUSIONS

Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.

Justice Involvement and Treatment Use Among Rural Veterans

Veterans in rural areas and veterans involved in the criminal justice system have experienced less access to, and use of, health care. However, there is limited information on the treatment needs and health care access of justice-involved veterans who live in rural areas. This study used national Veterans Health Administration data from fiscal year 2014 to examine the interactive effect of rural/urban residence and justice involvement on mental health and substance use disorder treatment entry among veterans diagnosed with mental health or substance use disorders. Of veterans residing in rural areas, 15,328 (2.5%) were justice-involved and 607,819 (97.5%) veterans had no known justice involvement. Among veterans in urban areas, 54,525 (4.3%) were justice-involved and 1,213,766 (95.7%) had no known justice involvement. Rural residence was associated with lower access to mental health or substance use disorder treatment in the non-justice-involved sample but not the justice-involved sample. Justice-involvement was associated with higher odds of entering mental health or substance use disorder treatment for veterans in rural and in urban areas. Substance use disorder treatment entry could be improved for all veterans, particularly rural veterans who are not justice-involved. Telehealth, outreach services, and integrated treatment may help address challenges to treatment entry experienced by rural veterans and justice-involved veterans.

Stratifying delays for assessment by type of substance to improve the probability of attendance in outpatient services

AIMS

1) To confirm the association between delay for assessment (DFA) and probability of first-time attendance in outpatient substance use disorder (SUD) treatment. 2) To evaluate whether this association varies by the type of primary substance for which the assessment was requested. 3) To assess the possibility of estimating differential DFAs to conform to equal probabilities of attendance across various types of primary substance.

METHODS

A prospective observational cohort of consecutive patients (N=1015) who requested a first-time assessment appointment at a publicly funded outpatient SUD treatment center in France between January 2014 and December 2015 was conducted. Logistic regression analyses were performed to evaluate associations between DFA (after log-transformation) and attendance and to provide estimates of attendance probability over time by the type of primary substance.

FINDINGS

After adjusting for gender, age and referral status, the attendance rate was observed to decrease significantly with longer DFA (OR=0.54; 95%CI: 0.44-0.66). The strength of this association differed across types of primary substance (p for heterogeneity <0.0001), with the strongest association being found for opioids (adjusted OR=0.21; 95%CI: 0.10-0.45). DFA was also associated with attendance for alcohol (OR=0.51; 95%CI: 0.37-0.71) and cannabis (OR=0.60; 95%CI: 0.37-0.96), but not for tobacco (OR=0.95; 95%CI: 0.60-1.50). Differential DFAs reflecting equal probabilities of attendance across types of substance could be estimated.

CONCLUSION

Our study suggests that the approach of stratifying DFAs by the type of primary substance could be helpful to improve the probability of first-time attendance in outpatient SUD treatment services.

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.

National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment

OBJECTIVES

We estimated national and state trends in opioid agonist medication-assisted treatment (OA-MAT) need and capacity to identify gaps and inform policy decisions.

METHODS

We generated national and state rates of past-year opioid abuse or dependence, maximum potential buprenorphine treatment capacity, number of patients receiving methadone from opioid treatment programs (OTPs), and the percentage of OTPs operating at 80% capacity or more using Substance Abuse and Mental Health Services Administration data.

RESULTS

Nationally, in 2012, the rate of opioid abuse or dependence was 891.8 per 100 000 people aged 12 years or older compared with national rates of maximum potential buprenorphine treatment capacity and patients receiving methadone in OTPs of, respectively, 420.3 and 119.9. Among states and the District of Columbia, 96% had opioid abuse or dependence rates higher than their buprenorphine treatment capacity rates; 37% had a gap of at least 5 per 1000 people. Thirty-eight states (77.6%) reported at least 75% of their OTPs were operating at 80% capacity or more.

CONCLUSIONS

Significant gaps between treatment need and capacity exist at the state and national levels. Strategies to increase the number of OA-MAT providers are needed.

Outcomes of a behavioral intervention to reduce HIV risk among drug-involved female sex workers

Although street-based female sex workers (FSWs) are highly vulnerable to HIV, they often lack access to needed health services and medical care. This paper reports the results of a recently completed randomized intervention trial for FSWs in Miami, Florida, which tested the relative efficacy of two case management interventions that aimed to link underserved FSWs with health services and to reduce risk behaviors for HIV. Participants were recruited using targeted sampling strategies and were randomly assigned to: a Strengths-Based/Professional Only (PO) or a Strengths-Based/Professional-Peer condition (PP). Follow-up data were collected 3 and 6 months post-baseline. Outcome analyses indicated that both intervention groups displayed significant reductions in HIV risk behaviors and significant increases in services utilization; the Professional-Peer condition provided no added benefit. HIV seropositive FSWs responded particularly well to the interventions, suggesting the utility of brief strengths-based case management interventions for this population in future initiatives.