The use of off-label medications in substance abuse treatment programs.

Background: Substance use disorder (SUD) treatment centers serve a population of clients who have diverse needs, and may desire or require access to varied treatments while seeking care for their SUDs. While pharmacotherapies have increased in popularity for the treatment of SUDs, adoption rates do remain quite low. But a wider array of pharmacotherapies has become available in recent years which may shift the trend. This article helps shed light on how variations in SUD treatment centers develop and persist with regard to the adoption and delivery of off-label medications. Methods: We use a nationally representative and longitudinal sample of SUD treatment centers in the US (N = 196). We use a logistic regression to analyze the relationship between organizational characteristics and offering any medications, off-label. We also use a negative binomial regression to analyze the relationship between organizational characteristics and the number of medications that were used off-label. Results: Our findings reveal that older centers, accredited centers, and centers that offer mental health screenings are all positively associated with the provision of off-label medication in SUD treatment. We also find a positive relationship between private funding and offering a greater number of off-label medications. Conclusions: Our results suggest that SUD clients who seek treatment from centers that offer medications off-label, may have access to a greater number of medication-assisted treatment options.

Smoking-related outcomes and associations with tobacco-free policy in addiction treatment, 2015-2016.

OBJECTIVE: This study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes. METHOD: Clients in 25 programs were surveyed in 2015 (N=1176) and 2016 (N=1055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016. RESULTS: There was one difference across years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=0.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=0.031), mean CPD decreased (10.62v. 8.24, p<0.001) and mean tobacco services received by clients increased (2.08v. 3.05, p<0.001). CONCLUSION: Addiction treatment programs, and agencies responsible for licensing, regulating and funding these programs, should implement tobacco-free grounds policies.

Insurance Receipt and Readiness for Opportunities under the Affordable Care Act: A National Survey of Treatment Providers for Substance Use Disorders.

This study measures the readiness of substance use disorder (SUD) treatment to use opportunities under the Affordable Care Act by examining Medicaid and private insurance acceptance between 2011 and 2013, as well as center characteristics associated with acceptance. Data for this study were from a random sample of SUD treatment centers in the United States. Interviews were conducted on site and face to face, with administrative and clinical directors. We employed logistic regression analyses to examine Medicaid acceptance and private insurance acceptance. We found that 59% of centers accepted Medicaid and 55% accepted private insurance. Accredited centers were more likely to accept Medicaid. A 12-step orientation and greater reliance on female clients were negatively associated with Medicaid acceptance. Larger centers and centers with a greater percentage of counselors with advanced degrees had greater odds of accepting private insurance. Centers that offered residential treatment had lower odds of accepting either Medicaid or private insurance. For private insurance acceptance, having a specific track for homeless patients lowered the odds of acceptance, as did having a greater percentage of Hispanic clients. Newly insured individuals under the ACA may have difficulty finding a program that accepts insurance. Future research should examine effects of Medicaid expansion on SUD treatment delivery.

Integration of Care in the Implementation of the Affordable Care Act: Changes in Treatment Services in a National Sample of Centers Treating Substance Use Disorders.

This study examined patterns of medicalization in substance use disorder (SUD) that are aligned with the goals of the Affordable Care Act (ACA). Using a nationally representative sample of SUD treatment programs, we examined changes in several treatment domains. While observed changes were modest, they were in directions that support the thrust of the ACA. Specifically, we found an increase in the percentage of treatment referrals from other health care providers. We found an increase in the number of physicians for programs that did have a physician on staff, and an increase in counselors certified in treating alcohol and drug addiction. There was significant growth in the availability of oral and injectable naltrexone but not of other pharmacotherapies. There was a decrease in support for the 12-step model and an increase on the emphasis of a medicalized treatment model. Finally, we found a shift away from federal block grants and other public funding, consistent with the expectations of the ACA. These data indicate that, while progress is slow, the environment of the recent past has been supportive of the goal of SUD treatment's integration into mainstream medical care.

The United States' Federal Parity Act and treatment of substance use disorders: Administrators' familiarity and perceptions of impact.

BACKGROUND: The 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) aims to secure parity in private insurance coverage between behavioral and other medical disorders in the United States (U.S.). This legislation represents an important change in the operating field of substance use disorder treatment, but to date, its impact on treatment centers has not been widely examined. The current study measured the extent of center leaders' familiarity with the MHPAEA and their perceptions of its overall impact on their centers. METHODS: Using a nationally representative sample of treatment centers in the U.S., we examined the extent of MHPAEA familiarity and its perceived impact as reported by treatment center leaders. We further employed logistic and ordered logistic regressions to determine personal and organizational characteristics associated with their reported familiarity and experienced impacts, including changes in the number of privately-insured clients seeking treatment and in the treatment coverage of those clients. RESULTS: We found that dissemination of parity information was low. Only 36% of administrators reported high levels of familiarity and 16% used professional sources of information. The majority of administrators (71%) reported no impact of the legislation on their organization, but those that reported any impact were more likely to state positive impact. Greater parity knowledge and perceived positive impacts were associated with administrator and organizational characteristics indicative of greater access to industry-specific knowledge, a medical model orientation, and reliance on private insurance revenue. CONCLUSION: This study demonstrates that dissemination of parity information is lacking and that the majority of leaders have yet to experience an impact of the MHPAEA. Leaders of centers with more sophisticated structures are most likely to be familiar with the legislation and perceive a positive impact. Research concerning the effective management of treatment centers, including environmental scanning techniques, continues to be needed.

Use of multiple tobacco products in a national sample of persons enrolled in addiction treatment.

OBJECTIVE: To explore use of tobacco products in relationship to marketing exposure among persons in addiction treatment. METHOD: A random sample of treatment programs was drawn from the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN). Participants in each program completed surveys concerning use of tobacco products (N=1113). Exposure to tobacco marketing and counter-marketing, advertising receptivity, and perceived health risks of smoking were tested for their association with use of multiple tobacco products. RESULTS: Prevalence of combustible cigarette use was 77.9%. Weekly or greater use of other products was: e-cigarettes (17.7%), little filtered cigars (8.6%), smokeless tobacco (5.2%), and standard cigars (4.6%) with 24.4% using multiple tobacco products. Compared to single product users, multiple product users smoked more cigarettes per day (OR=1.03, 95% CI 1.01-1.05, p<0.001), were more likely to have tried to quit (OR=1.41, 95% CI 1.02-1.96, p=0.041), reported greater daily exposure to advertising for products other than combustible cigarettes (OR=1.93, CI 1.35-2.75, p<0.001), and greater daily exposure to tobacco counter-marketing (OR=1.70, 95% CI: 1.09-2.63, p=0.019). CONCLUSION: Heavier smokers and those trying to quit may be more likely to use e-cigarettes, little filtered cigars, or smokeless tobacco and have greater susceptibility to their advertising. This highlights the importance of regulating advertising related to smoking cessation as their effectiveness for this purpose has not been demonstrated.

Detrimental Effects of "Stretch" Goals in Specialty Substance Use Disorder Treatment Organizations.

BACKGROUND: "Stretch" goals, a rarely examined concept that represents seemingly impossible, highly ambitious organizational goals ostensibly established to fill performance gaps and motivate employees, are examined within a sample of substance use disorder (SUD) treatment centers in the United States in terms of their prevalence and effects on organizational behavior. Stretch goals are defined as "seemingly impossible" goals intended to motivate employees to achieve high performance. In light of the high level of environmental change and unpredictability faced by SUD treatment centers in recent decades, we theorize that stretch goals would be both common and often detrimental (in terms of capacity utilization rate and efficiency) in these settings. METHODS: In a temporally lagged analysis of data from leaders of a representative U. S. national sample of 219 SUD treatment centers characterized by entrepreneurial management structures, we examined the prevalence of stretch goals and their impact on key outcome variables of capacity utilization rate and efficiency. RESULTS: Widespread adoption of stretch goals was found, with 43% of our sample falling within the stretch category. Stretch goals had a negative main effect on capacity utilization rate as compared to less ambitious challenging goals. Stretch and prior performance interacted to further predict capacity utilization rate, whereas stretch and slack resource availability interacted to predict center efficiency. DISCUSSION: Although stretch goals are frequently used in the SUD treatment industry, we find them mostly detrimental to performance. Stretch goals may enhance the efficiency of treatment centers with prior limited resource availability, but they are negatively associated with capacity utilization, especially in centers with a record of already strong performance. Despite the high prevalence of such goals and positive values centered on aspirational behavior, these results strongly suggest caution in such goal setting in SUD treatment centers.

The Relationship Between Client Characteristics and Wraparound Services in Substance Use Disorder Treatment Centers.

OBJECTIVE: The National Institute on Drug Abuse (NIDA) recommends a comprehensive treatment program for individuals with substance use disorder (SUD) in order to treat needs they often have in addition to their SUD. Specifically, NIDA suggests providing services related to the following issues: medical care, mental health care, HIV/AIDS, child care, educational, vocational, family counseling, housing, transportation, financial, and legal. By providing a comprehensive model that combines core and wraparound services, treatment centers can deliver a higher quality of treatment. In this article, we assessed the relationship between client characteristics and the availability of wraparound services in SUD treatment centers. METHOD: We combined two nationally representative samples of treatment centers and used a negative binomial regression and a series of logistic regressions to analyze the relationship between client characteristics and wraparound services. RESULTS: On average, centers offered fewer than half of the wraparound services endorsed by NIDA. Our results indicated that client characteristics were significantly related to the provision of wraparound services. Most notably, the proportion of adolescent clients was positively related to educational services, the proportion of female clients was positively related to child care, but the proportion of clients referred from the criminal justice system was negatively associated with the provision of multiple wraparound services. CONCLUSIONS: Our findings have important implications for SUD clients and suggest that, although centers are somewhat responsive to their clients' ancillary needs, most centers do not offer the majority of wraparound services.

Counselor training and attitudes toward pharmacotherapies for opioid use disorder.

BACKGROUND: Methadone and buprenorphine have been demonstrated to be effective in the treatment of opioid use disorder (OUD), especially when combined with psychosocial treatment. Despite buprenorphine's association with fewer withdrawal symptoms and lessened risk of abuse, compared with methadone, its adoption remains limited. Given the vital role that counselors may play in its successful implementation, their knowledge and perceptions of opioid agonist therapy may be facilitators or barriers to its acceptance. METHODS: Informed by diffusion theory, the current study examined perceptions of buprenorphine's and methadone's acceptability among 725 counselors employed in a nationally representative sample of substance use disorder treatment centers. First, we provided descriptive statistics about medication diffusion, extent of training received about the medications, and perceptions of acceptability of each medication. Then, we compared acceptability of opioid agonists with other treatment approaches for OUD. Finally, we conducted 2 ordinary least squares regressions to examine counselor acceptability of buprenorphine and of methadone. RESULTS: Descriptive statistics suggested that diffusion of information about buprenorphine and methadone was not complete, and training was not extensive for either medication. Counselors reported greater acceptability and training of buprenorphine compared with methadone. Methadone was rated as the least acceptable among all other treatment approaches. Multivariate analyses indicated regional differences, and that medication-specific training, adaptability, and educational attainment were positively related with perceptions of acceptability of either medication, even after controlling for organizational characteristics. Adherence to a 12-step orientation was negatively associated with acceptability. CONCLUSIONS: Dissemination of information about opioid agonist therapy is occurring. Nevertheless, the fact that 20% of counselors admitted not knowing enough about either buprenorphine's or methadone's effectiveness is surprising in light of the extensive literature documenting their effectiveness. Future research should focus upon different types of training that can inform physicians, counselors, and patients about the use of opioid agonist therapy.

The Diffusion of Acamprosate for the Treatment of Alcohol Use Disorder: Results From a National Longitudinal Study.

To consider how the Affordable Care Act may impact the diffusion of acamprosate, an evidence-based treatment for alcohol use disorder (AUD), the present study estimated the associations between acamprosate availability, Medicaid revenues, and private insurance revenues. Data were collected from organizational leaders of national samples of 307 specialty treatment centers in 2009-2012 and 372 treatment centers in 2011-2013. Notably, there was not a significant change in the percentage of organizations offering acamprosate over the study period. However, greater reliance on Medicaid and private insurance as sources of revenue was positively associated with the availability of acamprosate. In addition, acamprosate availability was positively associated with access to physicians and the presence of on-site primary medical care, while centers that placed greater emphasis on confrontational group therapy were significantly less likely to offer acamprosate for AUD treatment. To the extent that the ACA is expanding the number of insured individuals enrolled in Medicaid and commercial insurance sold through health insurance exchanges, this study suggests that the ACA may hold promise for expanding the availability of this EBP for AUD treatment. Future research is needed to measure whether this potential impact actually occurs within the specialty treatment system over time.

Service delivery and pharmacotherapy for alcohol use disorder in the era of health reform: Data from a national sample of treatment organizations.

BACKGROUND: Although there is a growing literature examining organizational characteristics and medication adoption, little is known about service delivery differences between specialty treatment organizations that have and have not adopted pharmacotherapy for alcohol use disorder (AUD). This study compares adopters and nonadopters across a range of treatment services, including levels of care, availability of tailored services for specific populations, treatment philosophy and counseling orientations, and adoption of comprehensive wraparound services. METHODS: In-person interviews were conducted with program leaders from a national sample of 372 organizations that deliver AUD treatment services in the United States. RESULTS: About 23.6% of organizations had adopted at least 1 AUD medication. Organizations offering pharmacotherapy were similar to nonadopters across many measures of levels of care, tailored services, treatment philosophy, and social services. The primary area of difference between the 2 groups was for services related to health problems other than AUD. Pharmacotherapy adopters were more likely to offer primary medical care, medications for smoking cessation, and services to address co-occurring psychiatric conditions. CONCLUSIONS: Service delivery differences were modest between adopters and nonadopters of AUD pharmacotherapy, with the exception of health-related services. However, the greater adoption of health-related services by organizations offering AUD pharmacotherapy represents greater medicalization of treatment, which may mean these programs are more strongly positioned to respond to opportunities for integration under health reform.

Implementation of Network for the Improvement of Addiction Treatment (NIATx) Processes in Substance Use Disorder Treatment Centers.

Internal process improvements embedded within the Network for Improvement of Addiction Treatment (NIATx) program are promising innovations for improving substance use disorder (SUD) treatment performance, such as engagement and retention. To date, few studies have examined the variables that may increase diffusion and implementation of NIATx innovations. This study investigates organizational characteristics associated with SUD treatment center utilization of NIATx process improvements in a sample of 458 treatment programs. Overall, 19% had utilized NIATx process improvements. After statistically controlling environmental factors, five organizational variables were associated with the likelihood that treatment centers used NIATx processes. Organization size, administrative intensity, membership in a provider association, and participation in National Institute on Drug Abuse's Clinical Trials Network were positively associated with the odds of utilizing NIATx processes, while the association for the level of slack resources was negative. The findings suggest that policies and related supportive efforts may be required to facilitate diffusion and implementation of NIATx processes to affect SUD treatment center performance and capacity.

Implementation of Electronic Health Records and Entrepreneurial Strategic Orientation in Substance Use Disorder Treatment Organizations.

OBJECTIVE: This research studied the relationships of the components of entrepreneurial strategic orientation (ESO) with implementation of electronic health records (EHRs) within organizations that treat patients with substance use disorders (SUDs). METHOD: A national sample of 317 SUD treatment providers were studied in a period after the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted (2009) and meaningful use EHR requirements were established (2010), but before implementation of the Affordable Care Act. The study sample was selected using stratified random sampling and was part of a longitudinal study of treatment providers across the United States. RESULTS: After we controlled for potentially confounding variables, four components of ESO had a significant relationship with EHR implementation. Levels of slack resources in an organization moderated the relationship of ESO with meaningful use of EHRs, increasing the strength of the relationship for some components but reducing the strength of others. CONCLUSIONS: From a policy and practice perspective, the results suggest that training and education to develop higher levels of ESO within SUD treatment organizations are likely to increase their level of meaningful use of EHRs, which in turn may enhance the integration of SUD treatment with primary medical providers, better preparing SUD treatment providers for the environmental changes of the Affordable Care Act.

Exploring Massachusetts Health Care Reform Impact on Fee-for-Service-Funded Substance Use Disorder Treatment Providers.

The Affordable Care Act (ACA) is forecast to increase the demand for and utilization of substance use disorder (SUD) treatment. Massachusetts implemented health reforms similar to the ACA in 2006-2007 that included expanding coverage for SUD treatment. This study explored the impact of Massachusetts health reforms from 2007 to 2010 on SUD treatment providers in Massachusetts, who relied on fee-for-service billings for more than 50% of their revenue. The changes across treatment facilities located in Massachusetts were compared to changes in other similar fee-for-service-funded SUD treatment providers in Northeast states bordering Massachusetts and in all other states across the US. From 2007-2010, the percentage changes for Massachusetts based providers were significantly different from the changes among providers located in the rest of the US for admissions, outpatient census, average weeks of outpatient treatment, residential/in-patient census, detoxification census, length of average inpatient and outpatient stays, and provision of medication-assisted treatment. Contrary to previous studies of publicly funded treatment providers, the results of this exploratory study of providers dependent on fee-for-service revenues were consistent with some predictions for the overall effects of the ACA.

Rural substance use treatment centers in the United States: an assessment of treatment quality by location.

BACKGROUND: While previous research has added to the understanding of rural residents' unique health challenges, much remains to be learned about the provision of substance use disorder (SUD) treatment in rural areas. A key question is difference in structural resources and quality of care between rural and urban treatment centers. OBJECTIVE: To examine differences in treatment quality in rural and urban centers and to determine if differences in treatment quality are contextualized by centers' structural resources. METHODS: Utilizing combined data from two representative samples of SUD treatment centers (n = 591), we used a series of multivariate regressions to analyze the association between center rurality and various indicators of structural characteristics and treatment quality. Interaction effects were further examined between structural characteristics and treatment quality indicators. RESULTS: We found that structural and quality differences between rural and urban treatment centers were present. Rural centers had reduced access to highly educated counselors, were more likely to be non-profit and dependent on public funding, offered fewer wraparound services, and had less diverse specialized treatment options. Our results also indicated that rural centers were less likely to prescribe buprenorphine as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Rural center access to a physician contextualized the association between center rurality and the more limited provision of wraparound services. CONCLUSION: Our findings suggest that treatment quality differs between urban and rural centers in complex ways that are subject to resource availability.

Medicaid, Private Insurance, and the Availability of Smoking Cessation Interventions in Substance Use Disorder Treatment.

OBJECTIVE: Integration of smoking cessation services in substance use disorder treatment would benefit many patients. Although prior studies have identified organizational characteristics associated with delivery of these services, less is known regarding associations between financial factors and the availability of smoking cessation services. This study examined whether reliance on Medicaid and private insurance revenues is associated with the availability of a formal counseling-based smoking cessation program and medications (sustained-release bupropion, varenicline, and nicotine replacement) within U.S. specialty treatment organizations. METHODS: Administrators of a national sample of 372 treatment organizations participated in face-to-face structured interviews from October 2011 to December 2013. Participants provided data regarding smoking cessation services, revenue sources, and other organizational characteristics. Multiple imputation was used to address missing data, and models were estimated by using logistic regression with adjustment for clustering of organizations within states. RESULTS: Greater reliance on Medicaid revenues was positively associated with the odds of offering counseling-based smoking cessation programs, sustained-release bupropion, varenicline, and nicotine replacement. For example, a 10-percentage point increase in Medicaid revenues was associated with a 12% increase in the odds of offering a smoking cessation program. Reliance on private insurance revenues was positively associated with the odds of offering the three medications. CONCLUSIONS: The findings point to future potential increases in the availability of smoking cessation services in the context of expanding insurance coverage under health care reform. Longitudinal research will be needed to examine whether this impact is realized.

Longitudinal Examination of Medical Staff Utilization in Substance Use Disorder Treatment Organizations.

This study examined changes in utilization of medical staff within organizations specializing in treatment of patients with substance use disorder (SUD) at two points in time (2007 and 2010). Utilization was calculated as the number of hours paid weekly for psychiatrists, physicians, nurses, and other medical staff working as employees or on contract. Study data come from a longitudinal national sample of 274 substance use disorder treatment centers. Average utilization of medical staff by these SUD treatment organizations increased by 26% from 2007 to 2010. The results showed that growing SUD treatment centers that obtained more referrals from health care providers, used case managers to coordinate comprehensive approaches to patient care, provided medication assisted treatment (MAT), and that were connected more closely with hospitals made increased use of medical staff over the 2007-2010 period. In 2010, these organizations seem to have been moving in directions consistent with trends forecasted for the SUD treatment environment after implementation of the Affordable Care Act.

Treatment strategy profiles in substance use disorder treatment programs: A latent class analysis.

BACKGROUND: Modern treatment options for substance use disorder are diverse. While studies have analyzed the adoption of individual evidence-based practices in treatment centers, little is known about the specific make-up of treatment strategy profiles in treatment centers throughout the United States. The current study used latent class analysis to profile underlying treatment strategies and to evaluate philosophical and structural supports associated with each profile. METHODS: Utilizing three aggregated and secondary datasets of nationally representative samples of substance use disorder treatment centers (N=775), we employed latent class analysis to determine treatment strategy profiles. Using multinomial logistic regression, we then examined organizational characteristics associated with each profile. RESULTS: We found three distinct treatment strategy profiles: centers that primarily relied on motivational interviewing and motivational enhancement therapy, centers that utilized psychosocial and alternative therapies, and centers that employed comprehensive treatments including pharmacotherapy. The multinomial logistic regression revealed that philosophical and structural center characteristics were associated with membership in the comprehensive class. Centers with philosophical orientations conducive to holistic care and pharmacotherapy-acceptance, resource-rich infrastructures, and an entrepreneurial reliance on insured clients were more likely to offer diverse interventions. All associations were significant at the .05 level. PRINCIPLE CONCLUSION: The findings from this study help us understand the general strategies of treatment centers. From a practical perspective, practitioners and clients should be aware of the variation in treatment center practices where they may offer or receive treatment.

Patient Violence Towards Counselors in Substance Use Disorder Treatment Programs: Prevalence, Predictors, and Responses.

Workplace violence disproportionately impacts healthcare and social service providers. Given that substance use and abuse are documented risk factors for the perpetration of violence, SUD treatment personnel are at risk for patient-initiated violence. However, little research has addressed SUD treatment settings. Using data nationally representative of the U. S., the present study explores SUD counselors' experiences of violent behaviors perpetrated by patients. More than half (53%) of counselors personally experienced violence, 44% witnessed violence, and 61% had knowledge of violence directed at a colleague. Counselors reported that exposure to violence led to an increased concern for personal safety (29%), impacted their treatment of patients (15%), and impaired job performance (12%). In terms of organizational responses to patient violence, 70% of organizations increased training on de-escalation of violent situations, and 58% increased security measures. Exposure to verbal assault was associated with age, minority, tenure, recovery status, 12-step philosophy, training in MI/MET, and higher caseloads of patients with co-occurring disorders. Exposure to physical threats was associated with age gender, minority, tenure, recovery status, and higher caseloads of patients with co-occurring disorders. Exposure to physical assault was associated with age, gender, and sample. Implications of these findings for organizations and individuals are discussed.