What can we learn from COVID-19 to improve opioid treatment? Expert providers respond.

BACKGROUND: The COVID-19 pandemic has had devasting effects on drug abuse treatment systems already stressed by the opioid crisis. Providers within opioid use disorder (OUD) outpatient treatment programs have had to adjust to rapid change and respond to new service delivery provisions such as telehealth and take-home medication. Using the COVID-19 pandemic and subsequent organizational challenges as a backdrop, this study explores providers' perspectives about strategies and policies that, if made permanent, can potentially improve access to and quality of OUD treatment. METHODS: This qualitative study was conducted in Los Angeles County, which has one of the largest substance use disorder (SUD) treatment systems in the United States serving a diverse population, including communities impacted by the opioid crisis. We collected qualitative interview data from 30 high-performing programs (one manager/supervisor per program) where we based high performance on empirical measures of access, retention, and program completion outcomes. The study team completed data collection and analysis using constructivist grounded theory (CGT) to describe the social processes in which the participating managers engaged when faced with the pandemic and subsequent organizational changes. We developed 14 major codes and six minor codes with definitions. The interrater reliability tests showed pooled Cohen's kappa statistic of 93 %. RESULTS: Our results document the impacts of COVID-19 on SUD treatment systems, their programmatic responses, and the strategic innovations they developed to improve service delivery and quality and which managers plan to sustain within their organizations. CONCLUSION: Providers identified three primary areas for strategic innovation designed to improve access and quality: (1) designing better medication utilization, (2) increasing telemedicine capacity, and (3) improving reimbursement policies. These strategies for system transformation enable us to use lessons from the COVID-19 pandemic to direct policy and programmatic reform, such as expanding eligibility for take-home medication and enhancing access to telehealth services.

Exploring Gender and Ethnoracial Differences and Trends in Methamphetamine Treatment.

Introduction: Given the significant rise in methamphetamine use and related mortality in the United States, it is critical to explore differences in treatment trends with particular attention to women and ethnoracial groups in hard-hit areas like Los Angeles County. Methods: We analyzed a large sample across 4 waves: 2011 (105 programs, 10 895 clients), 2013 (104 programs, 17 865 clients), 2015 (96 programs, 16 584 clients), and 2017 (82 programs, 15 388 clients). We completed a comparative analysis to identify differences across subgroups and a trend analysis of treatment episodes by gender and ethnoracial group to differentiate users of methamphetamine and users of other drugs. Results: Treatment clients using methamphetamine increased over time for each gender and race. There were also significant differences across age groups. Women comprised a greater proportion of treatment episodes involving methamphetamine use (43.3%) compared to all other drugs combined (33.6%). Latinas represented 45.5% of methadone-related admissions. Compared with other drug users, methamphetamine users had a lower successful treatment completion rate and were served by programs with less financial and culturally responsive capacity. Conclusions: Findings highlight a sharp increase in treatment admissions for methamphetamine users of all gender and ethnocultural groups. Women, especially Latinas, saw the most significant increases, with a widening gender gap over time. All subgroups of methamphetamine users had a lower treatment completion rate compared with users of other drugs, and critical differences existed in the programs where they received services.

Understanding the role of financial capacity in the delivery of opioid use disorder treatment.

Opioid treatment programs must have adequate financial capacity to sustain operations and deliver a high standard of care for individuals suffering from opioid use disorder. However, there is limited consistency in the health services literature about the concept and relationship of organizational financial capacity and key outcome measures (wait time and retention). In this study, we explored five common measures of financial capacity that can be applied to opioid treatment programs: (a) reserve ratio, (b) equity ratio, (c) markup, (d) revenue growth, and (e) earned revenue. We used these measures to compare financial capacity among 135 opioid treatment programs across four data collection points: 2011 (66 programs), 2013 (77 programs), 2015 (75 programs), and 2017 (69 programs). We examined the relationship between financial capacity and wait time and retention. Findings from the literature review show inconsistencies in the definition and application of concepts associated with financial capacity across business and social service delivery fields. The analysis shows significant differences in components of financial capacity across years. We observed an increase in average earned revenue and markup in 2017 compared to prior years. The interaction between minorities and markup was significantly associated with higher likelihood of waiting (IRR = 1.077, p < .05). Earned revenue (IRR = 0.225, p < .05) was related to shorter wait time in treatment. The interaction between minorities and equity ratio is also significantly associated with retention (IRR = 0.796, p < .05). Our study offers a baseline view of the role of financial capacity in opioid treatment and suggests a framework to determine its effect on client-centered outcomes.

Identifying gender differences in risk profiles and in opioid treatment outcomes in Los Angeles County.

Policies and programs that aim to minimize wait time to enter opioid use disorder (OUD) treatment and maximize retention respond to potential differences in female and male clients' risk profiles. We conducted multigroup latent class analysis using significant individual risk factors. Our sample included 13,453 opioid treatment episodes from 135 unique substance use disorder treatment programs in Los Angeles County, California, in four waves: 2011 (66 programs, 1035 clients), 2013 (77 programs, 3671 clients), 2015 (75 programs, 4625 clients), and 2017 (69 programs, 4106 clients). Groups at risk of waiting longer included clients who were female, had mental health issues, received medication for OUD, had criminal justice involvement, received mandated referrals, had children in child protective services, and had caretaker responsibilities. All clients with children in protective services were likely to wait longer than those not in protective services, but women waited longer. Findings highlight that: (a) women and men in OUD treatment have significant health and social problems; (b) female and male clients have distinct risk profiles; and (c) targeted services responding to risk profiles may improve treatment access and engagement. Findings have implications for health policy and program evaluation and planning in the delivery of treatment services considering gendered risk factors.

Disparities in opioid treatment access and retention among women based on pregnancy status from 2006 to 2017.

Background: The purpose of this study is to assess differences in wait time and retention in opioid use disorder (OUD) treatment among a sample of pregnant and non-pregnant women from low-income urban communities in Los Angeles, California. Methods: Data were collected in 9 waves consisting of consecutive years from 2006 to 2011, and then including 2013, 2015, and 2017. The sample consisted of 12,558 women, with 285 being pregnant and 12,273 being non-pregnant. We compared pregnant women with non-pregnant women at admission on key characteristics and relied on two multilevel negative binomial regressions analyses to examine factors related to access (days on the waiting list) and retention (days in treatment). Results: We detected disparities existed in access and retention. Pregnant women spent less time waiting to initate treatment than non-pregnant women and, once in treatment, had longer treatment episodes. Among pregnant women, clients identifying as Latina or Other waited longer to enter treatment compared to clients identifying as non-Latina White or Black. Women entering residential waited longer than those entering methadone or counseling services. Pregnant women were more likely to be in treatment longer if they had mental health issues, greater parenting responsibilities (number of children less than 18), and greater SUD severity (number of prior treatment episodes). Conclusions: Findings suggest pregnant women's access and retention can be improved through Medicaid coverage and through the implementation of a standard of care that includes MOUD (methadone) along with ancillary health and social services.

Disparities in expected driving time to opioid treatment and treatment completion: findings from an exploratory study.

BACKGROUND: Commuting time to treatment has been shown to affect healthcare outcomes such as engagement and initiation. The purpose of this study is to extend this line of research to investigate the effects of driving time to opioid programs on treatment outcomes. METHODS: We analyzed discharge survey data from 22,587 outpatient opioid use disorder treatment episodes (mainly methadone) in Los Angeles County and estimated the associated driving time to each episode using Google Maps. We used multivariable logistic regressions to examine the association between estimated driving time and odds of treatment completion after adjusting for possible confounders. RESULTS: Findings show an average driving time of 11.32 min and an average distance of 11.18 km. We observed differences in estimated driving time across age, gender, and socioeconomic status. Young, male, less formally educated, and Medi-Cal-ineligible clients drove longer to treatment. A 10-min drive was associated with a 33% reduction in the completion of methadone treatment plans (p < .01). CONCLUSION: This systemwide analysis provides novel time estimates of driving-based experiences and a strong relationship with completion rates in methadone treatment. Specifically, the result showing reduced treatment completion rates for drive times longer than 10 min may inform policies regarding the ideal geographic placement of methadone-based treatment programs and service expansion initiatives.

Identifying relative strength of methadone versus health and social services in comprehensive substance use disorder treatment using a variance decomposition approach.

BACKGROUND: The purpose of this study is to identify the relative strengths of association of medication and health and social services in comprehensive substance use disorder (SUD) treatment. OBJECTIVES: The study uses a novel variance decomposition method to assess the relative strength of association of six active ingredients of comprehensive SUD treatment: methadone medication, access services, SUD counseling, matched service ratio, client-provider relationship, and treatment duration. METHODS: The study uses data from the National Treatment Improvement Evaluation Study (1992-1997), a dataset with an unusual number of services and service strategies measured. The data include 3012 clients from 45 SUD treatment programs. Linear mixed models are used to assess the relation of service variables to the outcome of posttreatment substance use. Variance decomposition methods are used to assess the relative importance of the ingredients in the treatment model. RESULTS: Along with a random intercept and background variables, receipt of methadone accounted for the greatest relative strength of association at 35.4%, compared with 23.8% for treatment duration, 15.4% for client-provider relationship, and 11.2% for matched service ratio. Access and SUD counseling accounted for modest strengths of association at 1% and 3% each. CONCLUSION: Findings indicate somewhat greater strength of association of methadone compared with other services and service strategies and overall, reinforce the importance of both medication and services and service strategies in the design and development of effective models of service delivery. SIGNIFICANCE: This study, among the first to evaluate the relative importance of specific services and service strategies of comprehensive SUD treatment, provides insights relevant to the development of effective models of service delivery.

Gender disparities in access and retention in outpatient methadone treatment for opioid use disorder in low-income urban communities.

The purpose of this study was to detect and understand gender disparities in access and retention among outpatient methadone treatment programs located in low-income urban communities in Los Angeles, California. The study collected client- and program-level data in 4 waves in 2011, 2013, 2015, and 2017 from 34 publicly funded methadone treatment programs serving 11,169 clients with opioid use disorder (OUD). The sample included 29.8% female and 70.2% male clients, where 10.6% identified as Black or African American, 41.5% as Latino, 44.2% as non-Latino white, and 3.8% as Other. We conducted two multilevel negative binomial regression models to examine direct and moderated relationships related to both access (days on the waitlist) and retention (days in treatment) while accounting for clients clustered within programs. Gender disparities existed in both access and retention where women spent more time than men waiting to enter treatment but then remained in treatment longer. Further, female clients identifying as African American, Latino, and Other were at greater risk for shorter treatment duration than those who identified as non-Latino white and men. Overall, OUD clients receiving methadone treatment in low-income neighborhoods experienced barriers to access and retention in treatment associated with mental illness, family responsibilities, and use severity. OUD clients with MediCal insurance eligibility were consistently more likely to gain access to and remain in methadone treatment. Overall, findings call for improving treatment access and retention for women with OUD who receive methadone in outpatient methadone treatment programs through comprehensive, gender-specific, and evidence-based programming.

Gender disparities in opioid treatment progress in methadone versus counseling.

BACKGROUND: In the United States, the high dropout rate (75%) in opioid use disorder (OUD) treatment among women and racial/ethnic minorities calls for understanding factors that contribute to making progress in treatment. Whereas counseling and medication for OUD (MOUD, e.g. methadone, buprenorphine, naltrexone) is considered the gold standard of care in substance use disorder (SUD) treatment, many individuals with OUD receive either counseling or methadone-only services. This study evaluates gender disparities in treatment plan progress in methadone- compared to counseling-based programs in one of the largest SUD treatment systems in the United States. METHODS: Multi-year and multi-level (treatment program and client-level) data were analyzed using the Integrated Substance Abuse Treatment to Eliminate Disparities (iSATed) dataset collected in Los Angeles County, California. The sample consisted of 4 waves: 2011 (66 SUD programs, 1035 clients), 2013 (77 SUD programs, 3686 clients), 2015 (75 SUD programs, 4626 clients), and 2017 (69 SUD programs, 4106 clients). We conducted two multi-level negative binomial regressions, one per each outcome (1) making progress towards completing treatment plan, and (2) completing treatment plan. We included outpatient clients discharged on each of the years of the study (over 95% of all clients) and accounted for demographics, wave, homelessness and prior treatment episodes, as well as clients clustered within programs. RESULTS: We detected gender differences in two treatment outcomes (progress and completion) considering two outpatient program service types (MOUD-methadone vs. counseling). Clients who received methadone vs. counseling had lower odds of completing their treatment plan (OR = 0.366; 95% CI = 0.163, 0.821). Female clients receiving methadone had lower odds of both making progress (OR = 0.668; 95% CI = 0.481, 0.929) and completing their treatment plan (OR = 0.666; 95% CI = 0.485, 0.916) compared to male clients and receiving counseling. Latina clients had lower odds of completing their treatment plan (OR = 0.617; 95% CI = 0.408, 0.934) compared with non-Latina clients. CONCLUSIONS: Clients receiving methadone, the most common and highly effective MOUD in reducing opioid use, were less likely to make progress towards or complete their treatment plan than those receiving counseling. Women, and in particular those identified as Latinas, were least likely to benefit from methadone-based programs. These findings have implications for health policy and program design that consider the need for comprehensive and culturally responsive services in methadone-based programs to improve outpatient treatment outcomes among women.

Gender differences in trends for heroin use and nonmedical prescription opioid use, 2007-2014.

BACKGROUND: Trends in the current opioid epidemic in the United States show that use of heroin is increasing while nonmedical use of prescription opioids is slowing. Understanding gender differences in these trends is essential to efforts to address the opioid epidemic. This study compared gender difference in trends in heroin and nonmedical prescription opioid use in the U.S. between 2007 and 2014. METHODS: Data from the National Survey on Drug Use and Health (NSDUH) were used to trace prevalence and to estimate risk for heroin and nonmedical prescription opioid use in the last year for women and men. RESULTS: Prevalence rates in the total sample (N = 447,188) indicate a notable increase in heroin use and a steady decline in the nonmedical use of prescription opioids between 2007 and 2014 for both women and men. Women are increasing heroin use at a faster rate than men but decreasing nonmedical prescription opioid use at a slower rate than men. Overall, risk factors for both heroin use and nonmedical prescription opioid use are similar to other illicit substances, but the magnitude of associations indicates that women may be at greater risk for the nonmedical use of prescription opioids than for the use of heroin. CONCLUSIONS: Trend analyses reveal a linear increase in heroin use and a quadratic decline in nonmedical prescription opioid use at the population level. The differential rates of change between men and women in use of both opioids highlight the need for comprehensive, gender-sensitive approaches to prevention and treatment for both heroin and nonmedical prescription opioid use. Future research should continue to explore gender differences in treatment access, including access to medication-assisted treatments and treatments integrated with health and social services, especially for women.

Drug use among Asian Americans: Differentiating use by acculturation status and gender.

This study examined past-year drug use among Asian Americans with respect to ethnic subgroup, acculturation, and gender differences. Survey data were collected during the National Latino and Asian American Survey, a national epidemiological household survey of behavioral health prevalence and service utilization rates. The analytical sample consisted of 505 Filipino, 598 Chinese, 518 Vietnamese, and 466 other Asian respondents. Results indicated that among ethnic subgroups, Filipinos had the highest rates of drug use. Among all Asian Americans, those who were born in the United States, those with higher levels of English proficiency, males, those who were younger, those with lifetime prevalence of a major depressive episode, and those who were frequent drinkers were all more likely to have reported past-year drug use. Findings suggest the need to better understand the heterogeneous character of Asian American drug use when considering the provision of culturally competent and linguistically appropriate prevention and treatment services.

Gender disparities in utilization and outcome of comprehensive substance abuse treatment among racial/ethnic groups.

This study examined gender differences within Black, Latino, and White subgroups in the utilization of comprehensive services and their relation to posttreatment substance use. Survey data were collected during the National Treatment Improvement Evaluation Study (NTIES), a prospective, longitudinal, multisite study of substance abuse treatment programs and their clients in the United States. The analytic sample consisted of 1,812 blacks (734 women and 1,078 men), 486 Latinos (147 women and 339 men), and 844 whites (147 women and 339 men) from 59 service delivery organizations. Results related to service utilization indicated that compared to men, women in all racial and ethnic groups needed and received more services targeted to their needs and reported more positive relations with service providers. Gender was a significant moderator of the relationship between service receipt and treatment outcomes for all racial and ethnic groups, but especially for the Latino subsample. Findings point to the need to consider race-specific gender differences in the development of culturally competent, comprehensive substance abuse treatment.

Disparities in Latino substance use, service use, and treatment: implications for culturally and evidence-based interventions under health care reform.

BACKGROUND: The goal of this systematic literature review was to enhance understanding of substance use, service use, and treatment among Latino subgroups to improve access to care and treatment outcomes in an era of health care reform. METHODS: The authors used 13 electronic databases and manually searched the literature from January 1, 1978, to May 30, 2013. One hundred (69%) of 145 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus discussions and a content expert reconciled discrepancies. RESULTS: Current rates of alcohol and substance abuse among Latinos are comparable to or surpass other U.S. ethnic groups. Disparities in access and quality of care are evident between Latinos and other ethnic groups. As a heterogeneous group, Latinos vary by geographic region in terms of substance of choice and their cultural identity takes precedence over general ethnic identity as a likely determinant of substance abuse behaviors. There is growing research interest in systems influencing treatment access and adherence among racial/ethnic and gender minority groups. However, studies on Latinos' service use and immediate treatment outcomes have been both limited in number and inconsistent in findings. CONCLUSIONS: This review identified human capital, quality of care, and access to culturally responsive care as key strategies to eliminate disparities in health and treatment quality. Implications are discussed, including the need for effectiveness studies on Latinos served by systems of care that, under health care reform, are seeking to maximize resources, improve outcomes, and reduce variation in quality of care.

Disparities in completion of substance abuse treatment between and within racial and ethnic groups.

OBJECTIVE: To evaluate disparities in substance abuse treatment completion between and within racial and ethnic groups in publicly funded treatment in Los Angeles County, California. DATA SOURCE: The Los Angeles County Participant Reporting System with multicross-sectional annual data (2006-2009) for adult participants (n = 16,637) who received treatment from publicly funded programs (n = 276) for the first time. STUDY DESIGN: Retrospective analyses of county discharge and admission data. Hierarchical linear regressions models were used to test the hypotheses. DATA COLLECTION: Client data were collected during personal interviews at admission and discharge for most participants. PRINCIPAL FINDINGS: African Americans and Latinos reported lower odds of completing treatment compared with Whites. Within-group analysis revealed significant heterogeneity within racial and ethnic groups, highlighting primary drug problem, days of drug use before admission, and homelessness as significant factors affecting treatment completion. Service factors, such as referral by the criminal justice system, enabled completion among Latinos and Whites only. CONCLUSIONS: These findings have implications for reducing health disparities among members of racial and ethnic minorities by identifying individual and service factors associated with treatment adherence, particularly for first-time clients.

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

BACKGROUND: Wait time is among the most commonly cited barriers to access among individuals seeking entry to substance abuse treatment, yet relatively little is known about what contributes to it. OBJECTIVES: To address this gap, this study draws from a national sample of substance abuse treatment clients and programs to estimate the proportion of clients entering treatment who waited more than 1 month to receive it (outpatient, residential, or methadone) and to identify client and program characteristics associated with wait time. METHODS: This study used data from the National Treatment Improvement Evaluation Study (1992-1997). The data include 2920 clients from 57 substance abuse treatment programs. Generalized linear modeling was used to identify client and program characteristics associated with wait time to treatment entry. RESULTS: Results of modeling indicate that being African-American (OR: 1.40; CI: 1.04, 1.88), being referred by criminal justice (OR: 1.70; CI: 1.18, 2.43), and receiving methadone (OR: 3.90; CI: 1.00, 15.16) were associated with increased odds of waiting more than 1 month. Conversely, having a diagnosis of HIV/AIDS (OR: 0.38; CI: 0.19, 0.77) was associated with decreased odds of waiting for more than 1 month. CONCLUSION: A significant proportion of clients waited more than 1 month on enter treatment. Greater odds of such wait times were associated with being African-American, criminal justice-referred, and receiving methadone. SIGNIFICANCE: This study is the first to use a national sample to examine the prevalence of wait time to substance abuse treatment entry and to identify client and program characteristics associated with it.

Client-Provider relationship in comprehensive substance abuse treatment: differences in residential and nonresidential settings.

As the substance abuse service system shifts from primarily residential to primarily nonresidential settings, it becomes important to understand how substance abuse treatment processes and outcomes may vary across service setting. Research increasingly indicates that, along with specific treatment and service strategies, client-provider relationship is an important ingredient in effective substance abuse treatment. This study uses a moderator-mediator analysis of a comprehensive service model to examine how the relation between client-provider relationship and substance abuse treatment outcomes may differ in residential and nonresidential settings. The study used data collected for the National Treatment Improvement Evaluation Study, a prospective, cohort-based study of U.S. substance abuse treatment programs and their clients, with an analytic sample of 59 publicly funded service delivery units and 3,027 clients. Structural equation modeling is used to assess the structural relations and causal connections between treatment process and treatment outcome variables. Results indicate that for nonresidential settings, a better client-provider relationship is directly related to improved outcomes of treatment duration and reduced posttreatment substance use and is indirectly related to both outcomes through provision of services matched to client needs. In residential settings, the quality of the client-provider relationship is unrelated to process or outcome variables. The findings point to the importance of the client-provider relationship in all settings but particularly in outpatient settings where there are limited physical constraints on the treatment process.

Improving health and social outcomes with targeted services in comprehensive substance abuse treatment.

BACKGROUND: Improved life functioning along with substance use reduction is increasingly recognized as the definition of effective addiction treatment. OBJECTIVES: To assess whether targeted health and social services contribute to improved physical/mental health and employment. METHODS: This study used data from the National Treatment Improvement Evaluation Study (N = 3027) and modeled the improvement in physical/mental health and employment at discharge or 12 months after discharge compared with intake measures as a function of receipts of matched services. RESULTS: Receiving matched medical service improves physical health only at treatment discharge; receiving matched mental health services improves mental health at discharge and 12 months after discharge; receiving matched vocational services improves employment only 12 months after discharge. CONCLUSIONS: Need-service matching contributes to improved health and social outcomes when longitudinal assessments of treatment outcomes are used to evaluate treatment effectiveness. SCIENTIFIC SIGNIFICANCE: Study findings document the value of targeted services for achieving success in health and social functioning in comprehensive substance abuse treatment.