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CORK Bibliography: Treatment Access

44 citations. 2009 to present

Prepared: June 2011

Allan J; Kemp M. Aboriginal and non aboriginal women in New South Wales non governmental oganisation (NGO) drug and alcohol treatment and the implications for social work: Who starts, who finishes, and where do they come from? Australian Social Work 64(1): 68-83, 2011. (47 refs.)

Limited access to care is frequently identified as a reason for poor health in Indigenous communities. This study aimed to identify the proportion of Aboriginal women accessing mainstream non government organisation (NGO) drug treatment in New South Wales (NSW) compared to non Indigenous women. Statistical analysis of two NGO subsets of the Australian Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS-NMDS) for years 2005 to 2007 was conducted. A statistically significant relationship was found between gender and Indigenous status ( 2=4.582, df=1, p=.001) in the two stages of analysis. Among NSW Aboriginal people who have accessed episodes of drug and alcohol treatment in the NGO sector, there is a significantly greater proportion of females versus males (37%F vs 63%M, n=3,080 episodes) compared to the non Indigenous service users (29%F vs 71%M, n=21,791 episodes). Aboriginal women are more likely to be referred from criminal justice settings. However, both groups of women complete treatment at the same rate. Treatment providers' perceptions of their inability to successfully intervene with Aboriginal women may be a barrier to treatment. Agency client data should be examined for both race and gender details before treatment providers decide if what they supply is accessible to Aboriginal and Torres Strait Islander populations. This study demonstrates the importance of using evidence rather than assumptions about access to and effectiveness of service provision to Aboriginal women. Analysis of agency, State, and national datasets can inform policy and practice evaluations. Social workers can then support a more hopeful future for Aboriginal women, families, and communities.

Arfken CL; Johanson CE; di Menza S; Schuster CR. Expanding treatment capacity for opioid dependence with office-based treatment with buprenorphine: National surveys of physicians. Journal of Substance Abuse Treatment 39(2): 96-104, 2010. (24 refs.)

Office-based treatment of opioid dependence with buprenorphine has the potential to expand treatment capacity in the United States. However, nationally, little is known about the number, characteristics, and experiences of physicians certified to prescribe buprenorphine. Moreover, little is known about the impact of easing federal regulations on the number of patients a physician is allowed to treat concurrently. To address these questions, surveys of national samples of physicians certified to prescribe buprenorphine (2004-2008) were analyzed (N = 6,892). There has been a continual increase in the number of physicians certified to prescribe buprenorphine, increase in the mean number of patients treated by physicians, and decrease in patients turned away, coinciding temporally with easing of federal regulations. In addition, most physicians prescribed buprenorphine outside of traditional treatment settings. The U.S. experiment in expanding Schedule III-V medications for opioid dependence to physicians outside of formal substance abuse treatment facilities appears to have resulted in expanded capacity.

Aston S. Identities under construction: Women hailed as addicts. Health 13(6): 611-628, 2009. (41 refs.)

Despite continuing investigations of the efficacy of Canadian addiction treatment services and supports across a range of health care settings and socio-cultural groups, many systemic, geographic and ideological barriers to service provision for women still exist. Determining how current services and supports can become more congruent with women's gender-specific needs is a current research focus. Drawing on Butler's reformulation of Althusser's interpellation, this article explores the power of hailing, where hailing power lies, and how hailing operates in discourses about addiction that appear in women's talk of their encounters with addiction services and supports. The article briefly outlines Butler's understanding of interpellation and examines ways by which gender operates as both condition and effect in women becoming addicts. I argue that women's narratives reveal patterns of interaction that intersect and generate complex social meanings and identities, and serve to get women's attention in terms of seeing themselves as addicts. Further, I argue that powerful competing discourses concerning gender and the medicalization of addiction, hailed through these interactions, are taken up as lived realities by some women and resisted by others. Knowing how women are hailed to take up as their own, or resist, aspects of traditional and gendered discourses within addiction treatment and recovery communities can inform gender-compassionate service provision.

Babor TF. Drug Policy And The Public Good: A summary of the book. Addiction 105(7): 1137-1145, 2010. (30 refs.)

Drug Policy and the Public Good was written by an international group of scientists from the fields of addiction, public health, criminology and policy studies to improve the linkages between drug research and drug policy. The book provides a conceptual basis for evidence-informed drug policy and describes epidemiological data on the global dimensions of drug misuse. The core of the book is a critical review of the cumulative scientific evidence in five general areas of drug policy: primary prevention programmes in schools and other settings; health and social services for drug users; attempts to control the supply of drugs, including the international treaty system; law enforcement and ventures into decriminalization; and control of the psychotropic substance market through prescription drug regimes. The final chapters discuss the current state of drug policies in different parts of the world and describe the need for future approaches to drug policy that are coordinated and informed by evidence.

Batki SL; Canfield KM; Smyth E; Ploutz-Snyder R; Levine RA. Hepatitis C treatment eligibility and comorbid medical illness in methadone maintenance (MMT) and non-MMT patients: A case-control study. Journal of Addictive Diseases 29(3): 359-369, 2010. (52 refs.)

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p .01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p .001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).

Brucker D. Exploring the relationship between access and retention among substance abuse treatment admissions. Journal of Drug Issues 40(3): 553-576, 2010. (59 refs.)

To explore whether relationships exist among the timeliness of access to outpatient (OP) and intensive outpatient (IOP) substance abuse assessment and treatment and the participation retention and completion of treatment admission data from the State of Maine substance abuse treatment data system reflecting episodes both admitted and discharged during state fiscal year 2008 (N=6,157) were examined using linear and logistic regression techniques. Shorter wait times for assessment were found to lead to lower rates of treatment completion for both OP and IOP and to fewer numbers of sessions attended and shorter lengths of stay for IOP Shorter waits between assessment and treatment were found to lead to lower attendance at OP treatment sessions, shorter lengths of stay for OP and IOP, but higher rates of treatment completion for IOP Policy implications are discussed

Carroll CP; Triplett PT; Mondimore FM. The Intensive Treatment Unit: A brief inpatient detoxification facility demonstrating good postdetoxification treatment entry. Journal of Substance Abuse Treatment 37(2): 111-119, 2009. (41 refs.)

Inpatient detoxification is frequently used to treat substance use disorders, despite consistent findings that drug use soon after detoxification is the norm. A number of lines of evidence suggest the most rational means of improving outcomes after detoxification is to improve postdetoxification treatment entry. This report presents outcomes from the Intensive Treatment Unit (ITU), a brief inpatient detoxification unit in Baltimore, MD, found to have good postdischarge treatment entry outcomes. The patients followed were predominantly male African Americans in early middle age who were sequentially admitted to the unit (N = 134) and demonstrated severe social disruption and psychiatric comorbidity. More than 80% of the patients discharged from the ITU were admitted to treatment postdetoxification, with most going to long-term residential settings or recovery houses. Success was associated with seeking residential treatment, and failure was concentrated among the minority discharged with no plan for aftercare and those seeking outpatient treatments. The report explores patient and process factors associated with these outcomes and discusses the possibility that the ITU may be a model system for improving outcomes postdetoxification.

Conover CJ; Weaver M; Ang A; Arno P; Flynn PM; Ettner SL. Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders. AIDS Care 21(12): 1547-U91, 2009. (70 refs.)

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV + adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

Davidson H. Substance abuse and addiction in Family Courts: When it happens in a family -Aiding parents of substance-abusing adolescents. Family Court Review 47(April): 253-262, 2009. (44 refs.)

The article explores such issues as parents finding illegal drugs in the house or on their teen's person, various modalities of treatment and how family members are involved, how parents might secure residential evaluations for their youth without the necessity of juvenile court involvement (and why this is important), concerns about placing youth in unlicensed residential treatment facilities, health insurance coverage issues, home drug testing, and how past American Bar Association (ABA) policy on youth drug and alcohol abuse is being followed up with a new ABA project to aid parents of substance-abusing teenagers and their families. ... One-third of the teens who reported knowing a prescription drug abuser said that kids who abused prescription drugs got them from home, the medicine cabinet, or surreptitiously from parents. ... Finally, the ABA called for the preferred use of appropriate in-home and community-based prevention and intervention programs for at-risk children and youth, by having state law require enhanced governmental support so that families will have better access to these programs. ... Most private health insurance plans also impose benefit limitations and cost-sharing requirements on substance abuse and mental health services that are greater than those imposed on general medical services. It describes how past American Bar Association (ABA) policy on youth drug and alcohol abuse is being followed up with a new ABA project to aid parents of substance-abusing teenagers and their families.

Dickerson DL; Spear S; Marinelli-Casey P; Rawson R; Li LB; Hser YI. American Indians/Alaska Natives and substance abuse treatment outcomes: Positive signs and continuing challenges. Journal of Addictive Diseases 30(1): 63-74, 2011. (30 refs.)

Limited information is known with regard to substance abuse treatment outcomes among AI/ANs. Data retrieved from the Treatment System Impact (TSI) project and Methamphetamine Treatment Project (MTP) were used to compare treatment measures between a sample of AI/ANs and a matched comparison group. Our results revealed no significant differences between AI/ANs and the matched comparison group in treatment outcomes at 12-months post-treatment based on legal, employment, medical, and psychiatric measures. AI/ANs also received more family-related services (29.9% vs. 17.1%) and abuse-related services (21.3% vs. 7.6%). Addressing barriers to receiving substance abuse treatment and enhancing screening methods for AI/ANs are suggested.

Douglas N; Plugge E; Fitzpatrick R. The impact of imprisonment on health: What do women prisoners say? Journal of Epidemiology And Community Health 63(9): 749-754, 2009. (57 refs.)

Background: Women prisoners tend to suffer poor health on a range of indicators. This study sought to explore women prisoners' perceptions of the impact of imprisonment on their health. Methods: This qualitative study involved adult women prisoners in two closed local prisons. Focus groups and individual interviews were conducted. Results: Women prisoners reported that imprisonment impacted negatively upon their health. The initial shock of imprisonment, separation from families and enforced living with other women suffering drug withdrawal and serious mental health problems affected their own mental health. Over the longer term, women complained of detention in unhygienic facilities by regimes that operated to disempower them, including in the management of their own health. Women described responses to imprisonment that were also health negating such as increased smoking, eating poorly and seeking psychotropic medication. However, imprisonment could also offer a respite from lives characterised by poverty, social exclusion, substance misuse and violence, with perceived improvements in health. Conclusion: The impact of imprisonment on women's health was mixed but was largely perceived to be negative. Despite policy initiatives to introduce health promotion in prisons, there is little evidence of the extent to which this has been effective. The current policy climate in the UK makes it especially timely to examine the reported experience of women prisoners themselves about the impact of imprisonment on their health and to re-evaluate health promotion in women's prisons.

Gray D; Saggers S; Wilkes E; Allsop S; Ober C. Managing alcohol-related problems among Indigenous Australians: What the literature tells us. Australian and New Zealand Journal of Public Health 34(Supplement 1): S34-S35, 2010. (14 refs.)

Objective: To contextualise and provide an overview of two review papers - prepared as part of a larger research program - dealing with different aspects of the treatment of Indigenous Australians with alcohol-related problems. Method: The papers were reviewed thematically and compared to identify key issues raised in them. Findings: Together, the papers highlight the paucity of the evidence base for the provision of treatment for Indigenous Australians with alcohol-related problems. Among the key issues identified are: the need to engage with clients in culturally safe ways; practitioner, organisational and client barriers to engagement; the contexts in which Indigenous drinking and treatment take place; the need to develop rigorous methods of evaluation more appropriate to Indigenous cultural and service provision settings; and the importance of effective partnerships in the provision of services. Conclusion: For those working in the field, the reviews direct attention to the need to review and interrogate our current practice. They also provide clear directions for future research.

Gryczynski J; Schwartz R; O'Graduatey K; Jaffe J. Treatment entry among individuals on a waiting list for methadone maintenance. American Journal of Drug and Alcohol Abuse 35(5): 290-294, 2009. (25 refs.)

Background: Many methadone programs in the United States have waiting lists for care. Objectives: To examine specific predictors of treatment entry among individuals on a waiting list for methadone maintenance. Methods: Heroin users placed on a waiting list for methadone treatment (n = 120) were administered a urine screen for drug use and assessed with a battery of measures at study entry and at 4 month follow-up as part of a larger clinical trial. Logistic regression was used to examine hypothesized predictors of treatment entry. Outcomes for those failing to enter treatment were also examined. Results: Only 25 individuals (20.8%) entered treatment within four months of being placed on a waiting list. Intravenous drug users were more likely to enter treatment (p < .05) whereas cocaine users were less likely to do so (p < .01). Motivation did not predict treatment entry, and cocaine use did not moderate this relationship. There were some improvements in heroin use among those who did not enter treatment. Conclusions: Additional research is needed on the relationship between motivation and treatment entry. Programs may need to make special efforts to facilitate entry for treatment-seeking heroin users who also use cocaine. Scientific Significance: These findings have implications for improving access to methadone treatment.

Hadland SE; Kerr T; Li K; Montaner JS; Wood E. Access to drug and alcohol treatment among a cohort of street-involved youth. Drug and Alcohol Dependence 101(1-2): 1-7, 2009. (38 refs.)

Background: A number of options for treatment are available to Young drug users, but little is known about the youth who actually attempt to access such services. Here we identify characteristics of a cohort of street-involved youth and highlight commonly encountered barriers. Methods: From September 2005 to July 2007, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of 529 drug users aged 14-26 living in Vancouver, Canada. Participants who attempted to access any addiction services in the 6 months prior to enrollment were compared in univariate analyses and multiple logistic regression modeling of socio-demographic and drug-related factors. Results: Factors positively associated with attempting to access services included Aboriginal ethnicity (adjusted odds ratio [AOR] = 1.66 [1.05-2.62]), high school education (AOR = 1.66 [1.09-2.55]), mental illness (AOR = 2.25 [1.50-3.38]), non-injection crack use (AOR = 2.93 [1.76-4.89]), and spending >$50 on drugs per clay (AOR 2.13 [1.41-3.22]). Among those who experienced difficulty-accessing services, the most commonly identified barrier was excessively long waiting lists. In a Subgroup analysis comparing those who tried to access services but were unsuccessful to those who were successful, risk factors positively-associated with failure included drug bingeing(odds ratio [OR] = 2.86 [1.22-6.76]) and homelessness (OR = 3.86 [1.11-13.4]). Conclusions: in light of accumulating evidence that drug use among street youth is associated with risky health-related behaviors, improving access to treatment and other addiction services should remain an important Public health priority.

Kelly JF; Magill M; Stout RL. How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. (review). Addiction Research & Theory 17(3): 236-259, 2009. (133 refs.)

Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform our understanding of addiction recovery and the timing and content of alcohol-related interventions. Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO, Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational tests. A further six were included that had completed partial tests. Mechanisms examined fell into three domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results suggest AA helps individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research or support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by between-study differences in sampling, measurement, and assessment time-points, and by insufficient theoretical elaboration of recovery-related change. Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively self-regulated according to perceived need.

Knudsen HK; Studts JL; Boyd S; Roman PM. Structural and cultural barriers to the adoption of smoking cessation services in addiction treatment organizations. Journal of Addictive Diseases 29(3): 294-305, 2010. (41 refs.)

Few studies have examined associations between the availability of smoking cessation services in addiction treatment organizations and specific cultural, staffing, and resource barriers. Telephone interviews were conducted with administrators of 897 addiction treatment organizations in the United States. These data revealed that few programs had adopted the full bundle of five recommended tobacco-related intake procedures, and that less than half of programs offered any smoking cessation services. Barriers to adoption of the intake bundle and availability of services included organizational culture and low levels of staff skills. Adoption of cessation services was associated with center type, location in a hospital setting, levels of care, and organizational size. Although a substantial proportion of organizations offer smoking cessation services, expansion of these services and greater adoption of tobacco-related intake procedures are needed to address the needs of nicotine-dependent individuals in addiction treatment.

Kreek MJ; Tatal AH; Piccolo P. Treating chronic hepatitis C in recovering opiate addicts: Yes, we can. Digestive and Liver Disease 41(4): 308-310, 2009. (14 refs.)

Hepatitis has been a major problem identified in intravenous drug users (IDUs) since the 1950s. Pioneering research leading to methadone maintenance treatment as effective pharmacotherapy of opiate addiction was conducted among IDUs in New York City in the 1960s; prospective studies conducted between 1964 and 1972 reported that 60-70% of all heroin addicts entering methadone treatment had evidence of liver disease. It is now well known that a history of intravenous drug use is the single strongest risk factor for acquiring HCV infection and that prevalence of HCV, particularly in IDUs older than 40 years of age, is over 70%. Methadone or buprenorphine maintenance treatment can be equated to a long-term therapy for opiate addiction equivalent to that employed for other chronic diseases (i.e., diabetes, hypertension); however stigma towards patients receiving treatment for addiction is still widespread, both in the general public as well as among physicians and health providers. In this issue of Digestive and Liver Disease, the study by Belfiori et al. demonstrates that IDUs treated with pegylated interferon and ribavirin can achieve sustained virological response rates that are equivalent to those obtained in registration trials using these therapies. To obtain these responses, IDUs were treated by a multidisciplinary group consisting of infectious disease physicians, addiction medicine specialists, and psychiatrists. The success of their approach raises the question: why so many former opiate addicts are still not considered suitable candidates for antiviral therapy? The author examines a number of reasons, drawing upon data from the United States and Italy.

Lambrette G. Between drug addiction and abstinence. A search for alternatives or the co-construction of a problem accessible to a solution. Therapie Familiale 31(1): 49-64, 2010. (45 refs.)

Between drug addiction and abstinence. A search for alternatives or the co-construction of a problem accessible to a solution. The author exposes in the present article the reading and provision of strategic therapy in the field of toxicomany. In order to do this, he outlines the notions of problems, customer and objective. The proposed interventions in this framework have no other ambition than to allow the co-construction of a problem so that it becomes accessible to a solution and to look for alternatives adapted to the person according to the collected informations.

McCarty D; McConnell KJ; Schmidt LA. Priorities for policy research on treatments for alcohol and drug use disorders. Journal of Substance Abuse Treatment 39(2): 87-95, 2010. (48 refs.)

The Robert Wood Johnson Foundation's Substance Abuse Policy Research Program (SAPRP) supported 368 awards for nearly $560 million to complete policy research related to alcohol, tobacco, and illicit drug use and abuse. As part of its closure in 2009, SAPRP commissioned four papers that articulated policy research priorities for tobacco cessation and control, alcohol prevention, drug prevention, and addiction treatment. The papers were released at a Congressional Briefing on October 2, 2009 and are available on the SAPRP Web site (http: www.saprp.org/Research_Agenda.cfm). An abridged version of the treatment policy paper summarizes what we know, what we need to know, and research recommendations. The paper examines five categories of policy concerns that are likely to affect addiction treatment services over the next 5 years: (a) organization and delivery of care, (b) quality of care, (c) evidence-based practices, (d) access to care, and (c) financing, costs, and value of care.

Milloy MJS; Kerr T; Zhang R; Tyndall M; Montaner J; Wood E. Inability to access addiction treatment and risk of HIV infection among injection drug users recruited from a supervised injection facility. Journal of Public Health 32(3): 342-349, 2010. (76 refs.)

Treatment for drug addiction is effective in reducing the harms of injection drug use, including infection with HIV and/or hepatitis C. We sought to examine the prevalence and correlates of being unable to access addiction treatment in a representative sample of injection drug users randomly recruited from a supervised injection facility. Using generalized estimating equations, we determined the prevalence and factors associated with being unable to access addiction treatment. Between 1 July 2004 and 30 June 2006, 889 individuals completed at least one interview and were included in this analysis. At each interview, similar to 20% of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months. Being unable to access treatment was independently associated with recent incarceration, daily use of heroin and borrowing used syringes. In a secondary question, the majority of individuals reported waiting lists were the reason for being unable to access treatment. Given the independent association between inability to access addiction treatment and elevated HIV risk behavior, these results suggest expanding addiction treatment may contribute significantly to HIV prevention efforts in this population.

Murray RL; Bauld L; Hackshaw LE; McNeill A. Improving access to smoking cessation services for disadvantaged groups: A systematic review. (review). Journal of Public Health 31(2): 258-277, 2009. (61 refs.)

Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance. A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts. Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physician's registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups. There is limited evidence on effective strategies to increase access to cessation services for disadvantaged smokers. While many studies collected socioeconomic data, very few analysed its contribution to the results. However, some potentially promising interventions were identified which merit further research.

Myers B; Fakier N; Louw J. Stigma, treatment beliefs, and substance abuse treatment use in historically disadvantaged communities. African Journal of Psychiatry 12(3): 218-226, 2009. (21 refs.)

Objective: Access to substance abuse treatment among historically disadvantaged communities (HDCs) in Cape Town, South Africa is limited, despite a growing demand for services, Although research has reported on structural barriers to treatment access, nonstructural factors remain largely unexplored. The aim of this paper is to describe two nonstructural influences on the use of substance abuse treatment services for people from HDCs: stigma and negative beliefs about treatment. Method: Findings from the qualitative component of a multi-method study are reported. In-depth interviews were conducted with 20 key informants, all of whom worked or lived in HDCs in the greater Cape Town area. Content and thematic techniques were used to analyse data. Results: According to key informants (i) stigma towards individuals with substance use disorders was prevalent in HDCs and negatively impacted on attempts to access services; (ii) negative beliefs about the quality and effectiveness of treatment were commonplace and acted as barriers to the use of existing services; and (iii) several factors contributed to these nonstructural barriers including media representations of both individuals with substance use disorders and treatment facilities for these disorders. Conclusion: This paper moves beyond the description of structural barriers to treatment to describe how two nonstructural factors, stigma and negative beliefs about treatment, hinder treatment seeking for substance use disorders, Recommendations for addressing these barriers include efforts to (i) shift discourses about substance abuse treatment, (ii) improve service quality and (iii) address myths and misconceptions about treatment.

Myers BJ; Louw J; Pasche SC. Inequitable access to substance abuse treatment services in Cape Town, South Africa. Substance Abuse Treatment, Prevention and Policy 5: e-article 28, 2010. (30 refs.)

Background: Despite high levels of substance use disorders in Cape Town, substance abuse treatment utilization is low among people from disadvantaged communities in Cape Town, South Africa. To improve substance abuse treatment utilization, it is important to identify any potential barriers to treatment initiation so that interventions to reduce these barriers can be implemented. To date, substance abuse research has not examined the factors associated with substance abuse treatment utilization within developing countries. Using the Behavioural Model of Health Services Utilization as an analytic framework, this study aimed to redress this gap by examining whether access to substance abuse treatment is equitable and the profile of variables associated with treatment utilization for people from poor communities in Cape Town, South Africa. Methods: This study used a case-control design to compare 434 individuals with substance use disorders from disadvantaged communities who had accessed treatment with 555 controls who had not accessed treatment on a range of predisposing, treatment need and enabling/restricting variables thought to be associated with treatment utilization. A hierarchical logistic regression was conducted to assess the unique contribution that the need for treatment, predisposing and enabling/restricting variable blocks made on substance abuse treatment utilization. Results: Findings revealed that non-need enabling/restricting variables accounted for almost equal proportions of the variance in service utilization as the need for treatment variables. These enabling/restricting variables also attenuated the influence of the treatment need and predisposing variables domains on chances of treatment utilization. Several enabling/restricting variables emerged as powerful partial predictors of utilization including competing financial priorities, geographic access barriers and awareness of treatment services. Perceived severity of drug use, a need for treatment variable) was also a partial predictor of utilization. Conclusions: Findings point to inequitable access to substance abuse treatment services among people from poor South African communities, with non-need factors being significant determinants of treatment utilization. In these communities, treatment utilization can be enhanced by (i) expanding the existing repertoire of services to include low threshold services that target individuals with less severe problems; (ii) providing food and transport vouchers as part of contingency management efforts, thereby reducing some of the financial and geographic access barriers; (iii) introducing community-based mobile outpatient treatment services that are geographically accessible; and (iv) employing community-based outreach workers that focus on improving awareness of where, when and how to access existing treatment services.

Nahra TA; Alexander J; Pollack H. Influence of ownership on access in outpatient substance abuse treatment. Journal of Substance Abuse Treatment 36(4): 355-365, 2009

Marked changes in ownership and control in substance abuse treatment delivery have garnered the attention of providers and policymakers alike. The proliferation of private for-profit providers and the shift to a delivery system that may be more explicitly influenced by financial incentives are of particular concern for this vulnerable population. This work empirically addresses how treatment unit ownership affected access and retention between 1995 and 2005 in the United States. Regressions show statistically significant associations between unit ownership and both restricted treatment access and shortening of treatment duration for financial reasons. In comparison to private nonprofit and public units, private for-profit units were less likely to provide initial treatment access and reported shortened treatment for a greater percentage of clients unable to pay. Other organization characteristics, such as methadone-maintenance programs and managed care participation, also were associated with limiting treatment accessibility. While this work does not determine the underlying motivation behind access limitations, continued shifts in ownership structure should heighten the attention of policymakers.

Neblett RC; Hutton HE; Lau B; McCaul ME; Moore RD; Chander G. Alcohol consumption among HIV-infected women: impact on time to antiretroviral therapy and survival. Journal of Women's Health 20(2): 279-286, 2011. (46 refs.)

Objective: Alcohol use is prevalent among HIV-infected people and is associated with lower antiretroviral adherence and high-risk sexual and injection behaviors. We sought to determine factors associated with alcohol use among HIV-infected women engaged in clinical care and if baseline alcohol use was associated with time to combination antiretroviral therapy (cART) and death in this population. Methods: In an observational clinical cohort, alcohol consumption at the initial medical visit was examined and categorized as heavy, occasional, past, or no use. We used multinomial logistic regression to test preselected covariates and their association with baseline alcohol consumption. We then examined the association between alcohol use and time to cART and time to death using Kaplan-Meier statistics and Cox proportional hazards regression. Results: Between 1997 and 2006, 1030 HIV-infected women enrolled in the cohort. Assessment of alcohol use revealed occasional and hazardous consumption in 29% and 17% of the cohort, respectively; 13% were past drinkers. In multivariate regression, heavy drinkers were more likely to be infected with hepatitis C than nondrinkers (relative risk ratios [RRR] 2.06, 95% confidence interval [CI] 1.29-3.44) and endorse current drug (RRR 3.51, 95% CI 2.09-5.91) and tobacco use (RRR 3.85 95% CI 1.81-8.19). Multivariable Cox regression adjusting for all clinical covariates demonstrated an increased mortality risk (hazard ratio [HR] 1.40, 95% CI 1.00-1.97, p < 0.05) among heavy drinkers compared to nondrinkers but no delays in cART initiation (1.04 95% CI 0.81-1.34) Conclusions: Among this cohort of HIV-infected women, heavy alcohol consumption was independently associated with earlier death. Baseline factors associated with heavy alcohol use included tobacco use, hepatitis C, and illicit drug use. Alcohol is a modifiable risk factor for adverse HIV-related outcomes. Providers should consistently screen for alcohol consumption and refer HIV-infected women with heavy alcohol use for treatment.

O'Brien J; Geikie A; Jardine A; Oakes W; Salmon A. Integrating smoking care in community service organisations to reach disadvantaged people: Findings from the Smoking Matters project. Health Promotion Journal of Australia 21(3): 176-182, 2010. (40 refs.)

Issue addressed: Smoking rates among very disadvantaged populations groups are much higher than for the general Australian population. Smoking makes a significant contribution to the reduced health and material well-being experienced by these groups. Community service organisations have been suggested as a promising setting to provide smoking cessation support for disadvantaged people, but few initiatives have explored the feasibility of this strategy. Methods: The project involved work with five non-government community service organisations as demonstration sites for the integration of smoking care. Sites were offered staff training, smoking-care resources and policy support to address tobacco in the service environment and in their work with clients. Pre-and post-training surveys were undertaken with training participants and a follow-up survey was conducted after three months. Survey questions assessed staff members' confidence, knowledge and skills to address smoking, as well as changes in staff practice. Results: The response rate for the surveys before and after the training sessions was almost 100%, with 63 of the 64 participants providing post-training surveys. The response rate of the three-month follow-up survey was approximately 50% with 34 respondents. Findings: indicate that staff did develop confidence, skills and knowledge to address tobacco issues. Some organisations made changes to policy, such as introducing designated smoking areas and providing financial support for clients and staff to quit smoking. Practice change was evident among some staff, particularly in addressing smoking as part of routine case management and use of the 5A's brief intervention framework. Conclusions: The project findings lend support to the view that community service organisations could play a role in providing smoking care to disadvantaged people.

Office of Applied Studies, Substance Abuse and Mental Health Administration. The NSDUH Report: Alcohol Treatment - Need, Utilization, and Barriers. (April 9, 2009). Rockville MD: Substance Abuse and Mental Health Administration, 2009. (3 refs.)

The National Survey on Drug Use and Health (NSDUH) gathers information that can help to provide a better understanding of alcohol treatment needs, service utilization, and barriers. NSDUH classifies persons as needing treatment for an alcohol problem if they met the criteria for alcohol dependence or abuse or if they received specialty alcohol use treatment in the past year. Respondents were asked if there was any time in the past year when they felt they needed treatment for their alcohol use but did not receive it. Persons who felt the need for treatment but did not receive it were asked about their reasons for not receiving treatment. This issue of The NSDUH Report presents 2007 estimates of alcohol treatment need, receipt of treatment, and perceived need for treatment, as well as 2004 to 2007 combined estimates on the reasons for not receiving alcohol treatment among persons aged 12 or older. Summary: In 2007, 7.8% of persons aged 12 or older (an estimated 19.3 million persons) needed treatment for an alcohol problem in the past year. Of those who needed alcohol treatment in the past year 8.1% received treatment at a specialty substance use treatment facility, 4.5% did not receive treatment but felt they needed it, and 87.4% did not receive treatment and did not perceive a need for it. Only one quarter (27.9%) of those who did not receive alcohol treatment but felt they needed it made an effort to get treatment in the past year. Averages for 2004 to 2007 show that the most common reasons given for not receiving alcohol treatment among those who felt the need for it were not being ready to stop using alcohol (42.0%) and cost or insurance barriers (34.5%)

Public Domain

Palepu A; Marshall BDL; Lai C; Wood E; Kerr T. Addiction treatment and stable housing among a cohort of injection drug users. PLoS one 5(7): e11697, 2010. (48 refs.)

Background: Unstable housing and homelessness is prevalent among injection drug users (IDU). We sought to examine whether accessing addiction treatment was associated with attaining stable housing in a prospective cohort of IDU in Vancouver, Canada. Methods: We used data collected via the Vancouver Injection Drug User Study (VIDUS) between December 2005 and April 2010. Attaining stable housing was defined as two consecutive "stable housing" designations (i.e., living in an apartment or house) during the follow-up period. We assessed exposure to addiction treatment in the interview prior to the attainment of stable housing among participants who were homeless or living in single room occupancy (SRO) hotels at baseline. Bivariate and multivariate associations between the baseline and time-updated characteristics and attaining stable housing were examined using Cox proportional hazard regression models. Principal Findings: Of the 992 IDU eligible for this analysis, 495 (49.9%) reported being homeless, 497 (50.1%) resided in SRO hotels, and 380 (38.3%) were enrolled in addiction treatment at the baseline interview. Only 211 (21.3%) attained stable housing during the follow-up period and of this group, 69 (32.7%) had addiction treatment exposure prior to achieving stable housing. Addiction treatment was inversely associated with attaining stable housing in a multivariate model (adjusted hazard ratio [AHR] = 0.71; 95% CI: 0.52-0.96). Being in a partnered relationship was positively associated with the primary outcome (AHR = 1.39; 95% CI: 1.02-1.88). Receipt of income assistance (AHR = 0.65; 95% CI: 0.44-0.96), daily crack use (AHR = 0.69; 95% CI: 0.51-0.93) and daily heroin use (AHR = 0.63; 95% CI: 0.43-0.92) were negatively associated with attaining stable housing. Conclusions: Exposure to addiction treatment in our study was negatively associated with attaining stable housing and may have represented a marker of instability among this sample of IDU. Efforts to stably house this vulnerable group may be occurring in contexts outside of addiction treatment.

Parry CDH; Dewing S; Petersen P; Carney T; Needle R; Kroeger K et al. Rapid assessment of HIV risk behavior in drug using sex workers in three cities in South Africa. AIDS and Behavior 13(5): 849-859, 2009. (40 refs.)

A rapid assessment was undertaken with drug using commercial sex workers (CSWs) to investigate practices putting them at risk for contracting HIV. It included key informant (KI) (N = 67) and focus group (N = 10) interviews in locations with a high prevalence of drug use in Cape Town, Durban and Pretoria, South Africa. HIV testing of KIs was conducted. Cocaine, Ecstasy, heroin and methaqualone are used by CSWs prior to, during and after sex. Drugs enhance the sexual experience and prolong sex sessions. Interviews revealed inconsistent condom use among CSWs together with other risky sexual practices such as needle sharing. Among CSWs who agreed to HIV testing, 34% tested positive. Barriers to accessing drug treatment and HIV treatment and preventive services were identified. Interventions recognizing the role of drug abuse in HIV transmission should be prioritized, and issues of access to services, stigma and power relations must be considered.

Perron BE; Mowbray OP; Glass JE; DelvaJ; Vaughn MG; Howard MO. Differences in service utilization and barriers among Blacks, Hispanics, and Whites with drug use disorders. Substance Abuse Treatment, Prevention and Policy 5(e-journal 3), 2010. (33 refs.)

Background: Treatment for drug use disorders (DUD) can be effective, but only a small proportion of people with DUD seek or receive treatment. Research on racial and ethnic treatment differences and disparities remains unclear. Understanding racial and ethnic differences and disparities in drug treatment is necessary in order to develop a more effective referral system and to improve the accessibility of treatment. The purpose of the current study was to explore the role of race and ethnicity in service utilization. Methods: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), this study examined racial and ethnic differences in use of 14 types of treatment services for DUD and 27 different treatment barriers among persons who met lifetime criteria for a DUD. Multivariate logistic regression analyses were used to examine service utilization and barriers among the racial and ethnic groups, while adjusting for other sociodemographic and clinical variables. Results and discussion: Among Blacks, Hispanics and Whites in the overall NESARC sample, approximately 10.5% met criteria for at least one lifetime drug use disorder. Approximately 16.2% of persons with a lifetime DUD received at least one type of service. Overall, this study indicated that Whites were less likely to report receiving help for drug-related problems than Blacks, Blacks used a greater number of different types of services, and no racial and ethnic differences were observed with respect to perceived barriers to drug treatment. However, by examining types of services separately, a complex picture of racial and ethnic differences emerges. Most notably, Whites were most likely to use professional services, whereas Blacks were most likely to use 12-step and clergy. The service use pattern of Hispanics most resembled that of Whites. Conclusion: While structural barriers to accessing treatment were observed, broad-based educational programs and interventions that are appropriately targeted to racial and ethnic groups remains an important area for prevention and treatment.

Perut V; Labalette C; Sogni P; Ferrand I; Salmon-Ceron D; Vidal-Trecan G. Access to care of patients with chronic hepatitis C virus infection in a university hospital: Is opioid dependence a limiting condition? Drug and Alcohol Dependence 104(1-2): 78-83, 2009. (32 refs.)

Background: We aimed to examine access to care of opioid-dependent patients with chronic hepatitis C. Methods: A standardized form was used to conduct a retrospective survey from 1999 to 2003 in a French university hospital. All HCV RNA positive in- or outpatients who had not had a liver biopsy or anti-HCV treatment were included. Opioid-dependence was defined as active opioid drug use or being on opioid substitution treatment. Results: The survey included 580 patients; 137 (23.6%) were opioid-dependent. Fewer patients with than without current opioid dependence had had genotyping (40.1% versus 67.7%, p<0.001), liver biopsy (51.8% versus 62.8%, p = 0.022), and anti-HCV treatment (8.8% versus 18.3%, p = 0.008). Genotyping was independently, negatively, associated with: (1) current opioid-dependence (OR = 0.3, 95%CI = 0.2-0.5), (2) former opioid-dependence (OR = 0.5, 95%CI = 0.3-0.9), (3) unemployment (OR = 0.5, 95%CI = 0.3-0.7), and (4) HCV infection discovered by screening (OR = 0.5, 95%CI = 0.3-0.7). Access to liver biopsy was independently, negatively associated with current opioid-dependence (OR = 0.6, 95%CI = 0.4-0.9), but positively associated with alcohol consumption (OR = 2.0, 95%CI = 1.2-3.4) and abnormal ALT level (OR = 2.2, 95%CI = 1.5-3.2). Access to anti-HCV treatment was independently, negatively associated with HCV infection discovered by screening (OR = 0.5, 95%CI = 0.3-0.9), but positively associated with moderate hepatitis (OR = 6.8, 95%CI = 2.8-16.8), extensive fibrosis or cirrhosis (OR = 12.3, 95%CI = 5.5-27.5), abnormal ALT level (OR = 2.1, 95%CI = 1.3-3.6) and age (40-64 years) (OR = 1.9. 95%CI = 1.0-3.4). Conclusions: Genotyping and liver biopsies were performed less frequently on current opioid dependent patients. Absence of genotyping was also independently associated with unemployment and former opioid-dependence. Alcohol consumption or abnormal ALT levels favored access to biopsy. Histological grade strongly conditioned access to anti-HCV treatment.

Peterson JA; Schwartz RP; Mitchell SG; Reisinger HS; Kelly SM; O'Grady KE et al. Why don't out-of-treatment individuals enter methadone treatment programmes? International Journal of Drug Policy 21(1): 36-42, 2010. (54 refs.)

Background: Despite the proven effectiveness of methadone treatment, the majority of hero in-dependent individuals are out-of-treatment. Methods: Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment. Results: Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment. Conclusion: Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request,and working with corrections agencies to ensure continued methadone treatment upon incarceration.

Shannon K; Kerr T; Strathdee SA; Shoveller J; Montaner JS; Tyndall MW. Prevalence and structural correlates of gender based violence among a prospective cohort of female sex workers. British Medical Journal 339(article b2939), 2009. (46 refs.)

Objective: To examine the prevalence and structural correlates of gender based violence against female sex workers in an environment of criminalised prostitution. Design: Prospective observational study. Setting Vancouver, Canada during 2006-8. Participants Female sex workers 14 years of age or older (inclusive of transgender women) who used illicit drugs (excluding marijuana) and engaged in street level sex work. Main outcome measure Self reported gender based violence. Results Of 267 female sex workers invited to participate, 251 women returned to the study office and consented to participate (response rate of 94%). Analyses were based on 237 female sex workers who completed a baseline visit and at least one follow-up visit. Of these 237 female sex workers, 57% experienced gender based violence over an 18 month follow-up period. In multivariate models adjusted for individual and interpersonal risk practices, the following structural factors were independently correlated with violence against female sex workers: homelessness (adjusted odds ratio for physical violence (aOR(physicalviolence)) 2.14, 95% confidence interval 1.34 to 3.43; adjusted odds ratio for rape (aOR(rape)) 1.73, 1.09 to 3.12); inability to access drug treatment (adjusted odds ratio for client violence (aOR(clientviolence)) 2.13, 1.26 to 3.62; aOR(physicalviolence) 1.96, 1.03 to 3.43); servicing clients in cars or public spaces (aOR(clientviolence) 1.50, 1.08 to 2.57); prior assault by police (aOR(clientviolence) 3.45, 1.98 to 6.02; aOR(rape) 2.61, 1.32 to 5.16); confiscation of drug use paraphernalia by police without arrest (aOR(physicalviolence) 1.50, 1.02 to 2.41); and moving working areas away from main streets owing to policing (aOR(clientviolence) 2.13, 1.26 to 3.62). Conclusions: Our results demonstrate an alarming prevalence of gender based violence against female sex workers. The structural factors of criminalisation, homelessness, and poor availability of drug treatment independently correlated with gender based violence against street based female sex workers. Socio-legal policy reforms, improved access to housing and drug treatment, and scale up of violence prevention efforts, including police-sex worker partnerships, will be crucial to stemming violence against female sex workers.

Shorkey C; Windsor LC; Spence R. Assessing culturally competent chemical dependence treatment services for Mexican Americans. Journal of Behavioral Health Services & Research 36(1): 61-74, 2009. (35 refs.)

Mexican Americans struggling with chemical dependence are greatly underserved. Barriers to treatment include language, lack of culturally relevant services, lack of trust in programs, uninviting environments, and limited use and linkage with cultural resources in the community. This project aimed to develop a tool for assessing and planning culturally competent/relevant chemical dependence treatment services for Mexican Americans. Focus groups were conducted with experts in Mexican-American culture and chemical dependence from six substance abuse programs serving adult and adolescent Mexican Americans and their families. Sixty-two statements were developed describing characteristics of culturally competent/relevant organizations. Concept mapping was used to produce a conceptual map displaying dimensions of culturally competent/relevant organizations and Cronbach's alpha was calculated to assess the internal consistency of each dimension. Analysis resulted in seven reliable subscales: Spanish language (alpha = 0.84), counselor characteristics (alpha = 0.82), environment (alpha = 0.88), family (alpha = 0.84), linkage (alpha = 0.92), community (alpha = 0.86), and culture (alpha = 0.89). The resulting instrument based on these items and dimensions enable agencies to evaluate culturally competent/relevant services, set goals, and identify resources needed to implement desired services for both individual organizations and networks of regional services.

Slayter EM. Disparities in access to substance abuse treatment among people with intellectual disabilities and serious mental illness. Health & Social Work 35(1): 49-59, 2010. (60 refs.)

People with intellectual disabilities (ID) have experienced increasing levels of community participation since deinstitutionalization. This freedom has facilitated community inclusion, access to alcohol and drugs, and the potential for developing substance abuse (SA) disorders. People with ID, who are known to have high rates of co-occurring serious mental illness (SMI), may be especially vulnerable to the consequences of this disease and less likely to use SA treatment. Using standardized performance measures for SA treatment access (initiation, engagement), rates were examined retrospectively for Medicaid beneficiaries with ID/SA/SMI ages 12 to 99 (N = 5,099) and their counterparts with no ID/SA/SMI (N = 221,875). Guided by the sociobehavioral model of health care utilization, age-adjusted odds ratios and logistic regression models were conducted. People with ID/SA/SMI were less likely than their counterparts to access treatment. Factors associated with initiation included being nonwhite, living in a rural area, and not being dually eligible for Medicare; factors associated with engagement included all of the same and having a fee-for-service plan, a chronic SA-related disorder, or both. Social work policy and practice implications for improving the health of people with ID/SA/SMI through policy change, cross-system collaboration, and the use of integrated treatment approaches are discussed.

Small W; Van Borek N; Fairbairn N; Wood E; Kerr T. Access to health and social services for IDU: The impact of a medically supervised injection facility. Drug and Alcohol Review 28(4): 341-346, 2009. (28 refs.)

Introduction and Aims. Injection drug users (IDU) often experience barriers to conventional health-care services, and consequently might rely on acute and emergency services. This study sought to investigate IDU perspectives regarding the impact of supervised injection facility (SIF) use on access to health-care services. Design and Methods. Semi-structured qualitative interviews were conducted with 50 Vancouver-based IDU participating in the Scientific Evaluation of Supervised Injecting cohort. Audio-recorded interviews elicited IDU perspectives regarding the impact of SIF use on access to health and social services. Interviews were transcribed verbatim and a thematic analysis was conducted. Results. Fifty IDU, including 21 women, participated in this study. IDU narratives indicate that the SIF serves to facilitate access to health care by providing much-needed care on-site and connects IDU to external services through referrals. Participants' perspectives suggest that the SIF has facilitated increased uptake of health and social services among IDU. Discussion and Conclusions. Although challenges related to access to care remain in many settings, SIF have potential to promote health by facilitating enhanced access to health-care and social services through a model of care that is accessible to high-risk IDU.

Sterling S; Weisner C; Hinman A; Parthasarathy S. Access to treatment for adolescents with substance use and co-occurring disorders: Challenges and opportunities. (review). Journal of The American Academy of Child and Adolescent Psychiatry 49(7): 637-646, 2010. (76 refs.)

Objective: To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions. Method: We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits. Results: Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy. Conclusion: In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.

Stover H. Barriers to opioid substitution treatment access, entry and retention: A survey of opioid users, patients in treatment, and treating and non-treating physicians. European Addiction Research 17(1): 44-54, 2011. (32 refs.)

Background/Aims: Although the number of patients in opioid substitution treatment (OST) in Germany has increased in recent years, many dependent opioid users remain out of treatment. Project IMPROVE assessed attitudes and beliefs regarding barriers to OST. Methods: Data were collected from opioid-dependent individuals (using self-complete questionnaires) currently in treatment (n = 200) or not in treatment (n = 200), and OST-accredited physicians (using computer-aided telephone interviewing) who currently provided (n = 101) or did not provide OST (n = 51) from different regions in Germany. Results: Key results showed that OST was perceived as valuable and effective by physicians, patients and users but that OST access and provision were inadequate, especially outside of major cities. Conclusion: These findings are consistent with national data indicating a worsening imbalance between patient demand for treatment and the supply of available physicians accredited to provide it. Many physicians and patients were not aware of, or were not utilizing, therapeutic strategies that may help reduce misuse and diversion. Improvements in the regulatory framework for OST, and identifying additional sources of support and training, would encourage more accredited physicians to actively provide treatment and thus help to fully realize the benefits of currently available treatment options.

Taxman FS; Kitsantas P. Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis. Drug and Alcohol Dependence 103(Supplement 1): s43-s53, 2009. (57 refs.)

Objective to be addressed: The purpose of this study was to investigate the structural and organizational factors that contribute to the availability and increased capacity for substance abuse treatment programs in correctional settings. We used classification and regression tree statistical procedures to identify how multi-level data can explain the variability in availability and capacity Of substance abuse treatment programs in jails and probation/parole offices. Methods: The data for this study combined the National Criminal Justice Treatment Practices (NCJTP) Survey and the 2000 Census. The NCJTP Survey was a nationally representative sample of correctional administrators for jails and probation/parole agencies. The sample size included 295 substance abuse treatment programs that were classified according to the intensity of their services: high, medium, and low. The independent variables included jurisdictional-level Structural variables, attributes of the correctional administrators, and program and service delivery characteristics of the correctional agency. Results: The two most important variables in predicting the availability of all three types of services were stronger working relationships with other organizations and the adoption of a standardized Substance abuse screening tool by correctional agencies. For high and medium intensive programs, the capacity increased when an organizational learning strategy was used by administrators and the organization used a substance abuse screening tool. Implications on advancing treatment practices in correctional settings are discussed, including further work to test theories on how to better understand access to intensive treatment services. This study presents the first phase of understanding capacity-related issues regarding treatment programs offered in correctional settings.

Tempalski B; Cleland CM; Pouget ER; Chatterjee S; Friedman SR. Persistence of low drug treatment coverage for injection drug users in large US metropolitan areas. Substance Abuse Treatment, Prevention and Policy 5(e-article 23), 2010. (52 refs.)

Objectives: Injection drug users (IDUs) are at high risk for HIV, hepatitis, overdose and other harms. Greater drug treatment availability has been shown to reduce these harms among IDUs. Yet, little is known about changes in drug treatment availability for IDUs in the U.S. This paper investigates change in drug treatment coverage for IDUs in 90 metropolitan statistical areas (MSAs) during 1993-2002. Methods: We define treatment coverage as the percent of IDUs who are in treatment. The number of IDUs in drug treatment is calculated from treatment entry data and treatment census data acquired from the Substance Abuse and Mental Health Service Administration, divided by our estimated number of IDUs in each MSA. Results: Treatment coverage was low in 1993 (mean 6.7%; median 6.0%) and only increased to a mean of 8.3% and median of 8.0% coverage in 2002. Conclusions: Although some MSAs experienced increases in treatment coverage over time, overall levels of coverage were low. The persistence of low drug treatment coverage for IDUs represents a failure by the U.S. health care system to prevent avoidable harms and unnecessary deaths in this population. Policy makers should expand drug treatment for IDUs to reduce blood-borne infections and community harms associated with untreated injection drug use.

Webster JM; Dickson MF; Duvall JL; Clark DB. Rural and urban differences in Kentucky DUI offenders. Journal of Addiction Medicine 4(3): 186-190, 2010. (26 refs.)

Objectives: Recent national data suggest that the prevalence of driving under the influence (DUI) is higher in rural areas than in more urbanized areas of the United States. However, little is known about rural DUI offenders, particularly those living in very remote areas. This study was conducted to examine the similarities and differences between rural and urban DUI offenders. Based on recent research, it was expected that few differences would be found between rural and urban DUI offenders. Methods: This study examined a total of 21,135 substance abuse assessment records for persons convicted of DUI in Kentucky and who concluded treatment in 2005. Assessment records included demographic characteristics, Alcohol Use Disorders Identification Test scores, Drug Abuse Screening Test scores, and the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision substance use disorder checklist. Beale codes based on county of residence were used to create comparison groups. Results: Positive, and statistically significant, associations were found between rurality and Drug Abuse Screening Test scores, Diagnostic and Statistical Manual of Mental Disorders Fourth Edition substance abuse and dependence disorders, and rates of education/treatment noncompliance. Alcohol Use Disorders Identification Test scores were negatively associated with rurality. Conclusions: The study suggests that the problem severity among DUI offenders may be greater in rural areas. Given the lack of treatment services in rural areas, practitioners may face greater challenges in assessing and providing appropriate treatment for this group of DUI offenders, which may put them at greater risk for continued impaired driving.

Wenzel SL; Green HD; Tucker JS; Golinelli D; Kennedy DP; Ryan G et al. The social context of homeless women's alcohol and drug use. Drug and Alcohol Dependence 105(1/2): 16-23, 2009. (63 refs.)

Background: Substance use poses a significant threat to the health of women, and homeless women are more likely to use alcohol and drugs than other women. Addressing risk factors in this population requires a focus on the social context of substance use among homeless women. Methods: Participants were 445 homeless women who were randomly sampled and interviewed in shelter settings about the characteristics of their personal networks. Binomial logistic regressions predicted days of binge drinking and of using marijuana, crack, cocaine, and methamphetamine or other amphetamines in the past 6 months. Results: Homeless women with a greater proportion of heavy alcohol users in their personal networks had greater odds of engaging in binge drinking, and women with a greater proportion of drug users in their networks had greater odds of using marijuana, cocaine, crack, and methamphetamine or other amphetamines. Women with a greater proportion of individuals in their networks that they had met in school or through work had lower odds of marijuana, cocaine, and crack use. Conclusions: Findings suggest the importance of structural solutions in addressing homeless women's alcohol and drug use, including greater access to treatment and recovery support for alcohol and drug problems as well as depression, and enhancing employment and educational opportunities for homeless women.

Yang JL; Hammond D; Driezen P; O'Connor RJ; Li QA; Yong HH et al. The use of cessation assistance among smokers from China: Findings from the ITC China Survey. BMC Public Health 11: e-article 75, 2011. (32 refs.)

Background: Stop smoking medications significantly increase the likelihood of smoking cessation. However, there are no population-based studies of stop-smoking medication use in China, the largest tobacco market in the world. This study examined stop-smoking medication use and its association with quitting behavior among a population-based sample of Chinese smokers. Methods: Face-to-face interviews were conducted with 4,627 smokers from six cities in the ITC China cohort survey. Longitudinal analyses were conducted using Wave 1 (April to August, 2006) and Wave 2 (November 2007 to January 2008). Results: Approximately 26% of smokers had attempted to quit between Waves 1 and 2, and 6% were abstinent at 18-month follow-up. Only 5.8% of those attempting to quit reported NRT use and NRT was associated with lower odds of abstinence at Wave 2 (OR = 0.11; 95% Cl = 0.03-0.46). Visiting a doctor/health professional was associated with greater attempts to quit smoking (OR = 1.60 and 2.78; 95% Cl = 1.22-2.10 and 2.21-3.49 respectively) and being abstinent (OR = 1.77 and 1.85; 95% Cl = 1.18-2.66 and 1.13-3.04 respectively) at 18-month follow-up relative to the smokers who did not visit doctor/health professional. Conclusions: The use of formal help for smoking cessation is low in China. There is an urgent need to explore the use and effectiveness of stop-smoking medications in China and in other non-Western markets.

Zemore SE; Mulia N; Ye Y; Borges G; Greenfield TK. Gender, acculturation, and other barriers to alcohol treatment utilization among Latinos in three National Alcohol Surveys. Journal of Substance Abuse Treatment 36(4): 446-456, 2009

This study, using three waves of U.S. National Alcohol Surveys (1995-2005). examines lifetime alcohol treatment utilization and perceived treatment barriers among Latinos. The sample included 4,204 Latinos (2,178 women and 2,024 men); data were weighted. Analyses were linear and logistic regressions. Controlling for survey year, severity, and other covariates, male gender and English language interview predicted higher utilization generally and Alcoholics Anonymous use specifically; English interview was also associated with institutional treatment. (Effects for gender on general utilization were marginal.) Other predictors of utilization included older age, lower education, greater social pressures, greater legal consequences, greater dependence symptoms, and public insurance. Whereas men and women differed little on perceived barriers, analyses showed greater barriers among Spanish (vs. English) interviewees. Latina women's underutilization of alcohol treatment requires further research but may be partially explained by stigma. Associations between language of interview and treatment utilization imply a need for outreach and culturally sensitive programming.