Treatment Episode Data Set -- Admissions Research Articles

State inequities: Gaps in planned treatment for criminal legal referrals with opioid use disorder across two decades of US treatment admissions.

Criminal-legal (CL) referrals to addiction treatment have historically had low utilization of medications for opioid use disorder (MOUD). While state differences have been reported, an in-depth longitudinal analysis of state-by-state differences is lacking. The Substance Abuse and Mental Health Services Administration Treatment Episode Dataset-Admissions 2000-2020 provided data for individuals entering their initial treatment with an opioid as their primary substance. Outcome was planned use of MOUD, assessing odds ratio (OR) of CL referrals relative to non-CL referrals cumulatively over the 21-year period and as incremental change (change in relative disparity) using effect sizes, stratified by each state. 2,187,447 cases met the criteria. Planned MOUD occurred in 37.7% of non-CL clients versus 6.5% of CL clients (OR = 0.11, 95% confidence interval = 0.11-0.12). For all clients, planned MOUD increased from 2000 (33.9%) to 2020 (44.8%). This increase was blunted within CL clients, increasing from 2000 (6.4%) to 2020 (13.3%). Rhode Island saw the greatest improvements in equity. While rates of planned MOUD increased over the 21 years, a significant disparity persisted among CL clients in most states. As opioid use disorders and opioid-related overdoses are more prevalent among those involved with the CL system, improving this has high impact. Provides the most comprehensive analysis of state-by-state inequities in MOUD access for CL relative to non-CL referrals over a 21-year period through use of a national data set. Positive outliers are used as case examples for others to follow in pursuit of more equitable care.

Perinatal substance use treatment and criminal legal system referral trends

IntroductionTo guide improvements in treatment for pregnant persons with substance use disorders within the criminal legal system, treatment programs must first determine the primary substances of concern for this population. The objective of this study is to compare trends in specific substance use upon admission to treatment in pregnancy, based upon whether referrals originated from the criminal legal system or from another referral source. MethodsThis research accessed data on perinatal substance use (1995–2021) and referral sources from the Treatment Episode Data Set-Admissions (TEDS-A). Analyses use multiple logistic regressions to evaluate trends in primary substance use leading to treatment admission during pregnancy. ResultsApproximately 1 % (N = 536,948) of all substance use treatment admissions in TEDS-A were for pregnant people. Between 1995 and 2021, the percentage of treatment admissions increased for primary methamphetamine use (10 % to 27 %), primary opioid use (21 % to 38 %), and primary cannabis use (9 % to 18 %), and decreased for primary cocaine use (32 % to 6 %) and primary alcohol use (26 % to 11 %). By 2021, treatment admissions referred from criminal legal agencies were more likely to primarily be for primary methamphetamine use (33 % vs 25 %) and less likely to be for primary opioid use (22 % vs 42 %) compared to other referral sources. ConclusionsTrends in substance use treatment during pregnancy have changed substantially over the past few decades and emphasize the unique needs of patients referred to treatment by the criminal legal system. Treatment programs must therefore adapt to fluctuating trends in perinatal substance use. In particular, it is important to expand programs that prioritize treatment of methamphetamine use disorder for pregnant people referred through criminal legal agencies.

Prevalence and predictors of medication for opioid use disorder among reproductive-aged women

BackgroundWomen of reproductive age would benefit from treatment of opioid use disorder (OUD) prior to pregnancy to improve maternal and infant outcomes. In this study, we aimed to identify the prevalence of medication for OUD (MOUD) and characterize correlates of MOUD receipt among 12–49-year-old women with OUD seeking treatment in publicly funded substance use disorder treatment programs at the time of their first treatment episode. MethodsThis cross-sectional study explores the demographic and clinical characteristics of women of reproductive age with OUD receiving publicly funded substance use treatment services. We used data from the concatenated 2015–2021 Treatment Episode Data Set–Admissions (TEDS-A), which documents demographic and clinical characteristics of patient admissions to publicly funded substance use treatment services in the United States. ResultsIn the sample of females aged 12–49 with no prior treatment admissions and primary OUD (n=325,512), 40.53% received MOUD (n=131,930), including 39.40% of non-pregnant women (n=115,315) and 52.79% of pregnant women (n=8423). Pregnant women had significantly higher odds of receiving MOUD (aOR = 2.42, 95%CI: 2.30, 2.54) compared to non-pregnant women. Non-white race, treatment setting, and treatment self-referral were also associated with higher levels of MOUD. ConclusionsWe identified a significant unmet need among both pregnant and non-pregnant women with OUD seeking care in publicly funded treatment clinics. While women who are pregnant are significantly more likely to receive evidence-based treatment with MOUD, still 47.21% of pregnant women did not receive MOUD. All reproductive-aged women with OUD should be offered evidence-based treatment options, including MOUD.

Estimated Number of Injection-Involved Overdose Deaths in US States From 2000 to 2020: Secondary Analysis of Surveillance Data.

In the United States, both drug overdose mortality and injection-involved drug overdose mortality have increased nationally over the past 25 years. Despite documented geographic differences in overdose mortality and substances implicated in overdose mortality trends, injection-involved overdose mortality has not been summarized at a subnational level. We aimed to estimate the annual number of injection-involved overdose deaths in each US state from 2000 to 2020. We conducted a stratified analysis that used data from drug treatment admissions (Treatment Episodes Data Set-Admissions; TEDS-A) and the National Vital Statistics System (NVSS) to estimate state-specific percentages of reported drug overdose deaths that were injection-involved from 2000 to 2020. TEDS-A collects data on the route of administration and the type of substance used upon treatment admission. We used these data to calculate the percentage of reported injections for each drug type by demographic group (race or ethnicity, sex, and age group), year, and state. Additionally, using NVSS mortality data, the annual number of overdose deaths involving selected drug types was identified by the following specific multiple-cause-of-death codes: heroin or synthetic opioids other than methadone (T40.1, T40.4), natural or semisynthetic opioids and methadone (T40.2, T40.3), cocaine (T40.5), psychostimulants with abuse potential (T43.6), sedatives (T42.3, T42.4), and others (T36-T59.0). We used the probabilities of injection with the annual number of overdose deaths, by year, primary substance, and demographic groups to estimate the number of overdose deaths that were injection-involved. In 2020, there were 91,071 overdose deaths among adults recorded in the United States, and 93.1% (84,753/91,071) occurred in the 46 jurisdictions that reported data to TEDS-A. Slightly less than half (38,253/84,753, 45.1%; 95% CI 41.1%-49.8%) of those overdose deaths were estimated to be injection-involved, translating to 38,253 (95% CI 34,839-42,181) injection-involved overdose deaths in 2020. There was large variation among states in the estimated injection-involved overdose death rate (median 14.72, range 5.45-31.77 per 100,000 people). The national injection-involved overdose death rate increased by 323% (95% CI 255%-391%) from 2010 (3.78, 95% CI 3.33-4.31) to 2020 (15.97, 95% CI 14.55-17.61). States in which the estimated injection-involved overdose death rate increased faster than the national average were disproportionately concentrated in the Northeast region. Although overdose mortality and injection-involved overdose mortality have increased dramatically across the country, these trends have been more pronounced in some regions. A better understanding of state-level trends in injection-involved mortality can inform the prioritization of public health strategies that aim to reduce overdose mortality and prevent downstream consequences of injection drug use.

Factors associated with receipt of medication for opioid use disorder among pregnant individuals entering treatment programs in the U.S.

BackgroundOpioid use disorder (OUD) among pregnant individuals in the U.S. has been on the rise, and carries significant health risks if left untreated. Despite the effectiveness of medication for opioid use disorder (MOUD), rates of treatment utilization remain low, and access varies by state. This study seeks to expand on what is known about the utilization of MOUD by estimating annual percentages of MOUD use among treatment admissions among pregnant individuals across all 50 states and U.S. regions. The study also examines how pregnant people experiencing OUD are referred to substance use treatment programs to better understand which referral sources are most effective at linking them to MOUD. MethodsThis study estimated MOUD utilization among pregnant admissions over a 9-year period, identifying trends in the use of this treatment, using national and state level data from the Treatment Episode Dataset-Admissions (TEDS-A). The sample were pregnant females who admitted to treatment with opioids as a primary substance use problem, in all 50 states, from 2010 to 2018. The study examined the referral pathways through which pregnant individuals enter treatment, identifying variations in how they are linked with MOUD. A binary logistic regression was conducted to estimate significant sociodemographic characteristics and referral sources associated with MOUD receipt in treatment. ResultsAmong admissions who reported both pregnancy and OUD across nine years (n= 84,492), the average percentage of MOUD use was 50.8%. Average annual MOUD use was highest in the Northeast region (63.42%), and lowest in the South (34.01%). Maine had the highest MOUD use, for an average of 81.99% across all years. Pregnant individuals who were self-referred to treatment comprised the largest percentage of admissions leading to MOUD use (62.1%), and those referred by the criminal justice system or other legal entity resulted in the lowest MOUD use across years (23.6%). Binary logistic regression results found that race, education, employment status, and referral source were significantly associated with MOUD receipt in 2018; specifically, individuals with a higher education, those were unemployed, and those who were referred to treatment by another substance use or healthcare provider or from the criminal or legal system, were significantly less likely to receive MOUD. ConclusionThis study estimated that an average of approximately half of admissions who were pregnant with OUD received MOUD as part of their treatment plans, and identified regional and state trends which can be further investigated to understand factors contributing to these geographical variations in MOUD access. Also notable were findings pertaining to low MOUD receipt among those referred from criminal or legal entities, warranting further investigation. These findings can lead to a better understanding of which referral sources to treatment can act as effective pathways to MOUD, and best practices to link pregnant individuals with evidence-based care.

Predicting Co-Occurring Mental Health and Substance Use Disorders in Women: An Automated Machine Learning Approach

Significant clinical overlap exists between mental health and substance use disorders, especially among women. The purpose of this research is to leverage an AutoML (Automated Machine Learning) interface to predict and distinguish co-occurring mental health (MH) and substance use disorders (SUD) among women. By employing various modeling algorithms for binary classification, including Random Forest, Gradient Boosted Trees, XGBoost, Extra Trees, SGD, Deep Neural Network, Single-Layer Perceptron, K Nearest Neighbors (grid), and a super learning model (constructed by combining the predictions of a Random Forest model and an XGBoost model), the research aims to provide healthcare practitioners with a powerful tool for earlier identification, intervention, and personalised support for women at risk. The present research presents a machine learning (ML) methodology for more accurately predicting the co-occurrence of mental health (MH) and substance use disorders (SUD) in women, utilising the Treatment Episode Data Set Admissions (TEDS-A) from the year 2020 (n = 497,175). A super learning model was constructed by combining the predictions of a Random Forest model and an XGBoost model. The model demonstrated promising predictive performance in predicting co-occurring MH and SUD in women with an AUC = 0.817, Accuracy = 0.751, Precision = 0.743, Recall = 0.926 and F1 Score = 0.825. The use of accurate prediction models can substantially facilitate the prompt identification and implementation of intervention strategies.

Why Are Adolescent Cannabis Use Disorder Treatment Admissions Declining in the US? The Mediated Pathway of State Treatment Admissions Rates before and after Recreational Cannabis Legalization

Purpose: State-level prevalence data are used to investigate whether recreational cannabis legalization moderates the mediated pathway from the perception of low risk of harm, to cannabis use, to cannabis use disorder (CUD) treatment admissions, among adolescents (age 12–17) in the US. Methods: Annual state prevalence measures of perception of low risk, cannabis use, and CUD treatment admissions between 2008 and 2019 (N = 542 state-year observations) were collected from the National Survey on Drug Use and Health (NSDUH) and the Treatment Episode Dataset – Admissions (TEDS-A). A two-way fixed effects (state and year) moderated mediation model was used to test whether recreational legalization moderated the indirect effect of perception of low risk on treatment admissions via cannabis use. Results: A positive indirect effect of perceiving cannabis as low risk on CUD treatment admissions via cannabis use was observed prior to legalization but not afterwards. After legalization, the positive association of perceiving cannabis as low risk with cannabis use was strengthened, and the positive association of cannabis use with treatment admissions was suppressed, as compared to before legalization. Discussion: Recreational legalization may alter the social acceptability and medical self-administration of cannabis, potentially leading to CUD treatment utilization decline among adolescents even as risk factors for CUD increase. Linking recreational cannabis legalization to advancing awareness of the health risks associated with adolescent cannabis use and promoting adolescent CUD treatment engagement through mHealth approaches and primary care providers are key to addressing potential adolescent health challenges brought about by expanding cannabis legalization.

Evidence of "Repeated Admission Bias" Among Those Who Use Injection Drugs Across 2 Decades of US Treatment Admissions: 2000-2020.

Encounter-based datasets like the Treatment Episode Dataset-Admissions (TEDS-A) are used for substance use-related research. Although TEDS-A reports the number of previous treatment admissions, a limitation is this reflects encounters, not people. We sought to quantify the methodologic bias incorporated by using all encounters versus initial encounters and assess if this risk is evenly distributed across all routes of drug administration. TEDS-A 2000-2020 dataset with nonmissing primary substance data was used. Of the data, 3.17% were missing the usual administration route, and 11.9% were missing prior admission data. Prior admissions are documented as 0 through 4, then binned for 5 or greater (5+). Risk of admission bias was defined as odds ratio (OR RAB ): odds of total admissions relative to the odds of the first admission. Bootstrap confidence intervals were generated (5000 iterations) across administration routes and demographics; however, their widths were <0.0055 and not reported. There were 38,238,586 admissions over the 21 years, with 13,865,517 (41.2%) first admissions. Of all admissions, 15.7% indicated injection drug use (IDU); 26.3% of encounters reporting IDU were in the 5+ group. This resulted in an OR RAB of 1.77. White enrollees had an elevated OR RAB (1.05), whereas among Latinos, OR RAB was low (0.74). Using encounter-based datasets can introduce bias when including all admissions versus exclusively initial treatment episodes. This report is the first to quantify this bias and shows that individuals with IDU are at highest risk for returning to treatment, thereby over-representing this method of use when all encounters are used.

Racial and Ethnic Differences in Heroin, Methamphetamine, and Cocaine Use, Treatment, and Mortality Trends in 3 National Data Sources-United States, 2010-2019.

As overdose deaths continue to rise, public health officials need comprehensive surveillance data to design effective prevention, harm reduction, and treatment strategies. Disparities across race and ethnicity groups, as well as trends in substance use, treatment, or overdose deaths, have been examined individually, but reports rarely compare findings across multiple substances or data sources. To provide a broad assessment of the overdose crisis, we describe trends in substance use, treatment, and overdose mortality across racial and ethnic groups for multiple substances. We conducted a longitudinal, cross-sectional analysis comparing trends. We identified self-reported use from the National Survey on Drug Use and Health, substance use treatment admissions from the Treatment Episode Data Set-Admissions, and overdose deaths from the CDC's Multiple Cause of Death files. We measured rates of substance use, treatment, and deaths involving heroin, methamphetamine, and cocaine among United States adults from 2010 to 2019. Heroin, methamphetamine, and cocaine use increased, though not all changes were statistically significant. Treatment admissions indicating heroin and methamphetamine increased while admissions indicating cocaine decreased. Overdose deaths increased among all groups: methamphetamine (257%-1,115%), heroin (211%-577%), and cocaine (88%-259%). Changes in rates of use, treatment, and death for specific substances varied by racial and ethnic group. Substance use, treatment, and overdose mortality changed considerably, though not always equivalently. Identifying diverging trends in substance-related measures for specific substances and racial and ethnic groups can inform targeted investment in treatment to reduce disparities and respond to emerging changes in the overdose crisis.

OLDER ADULT SUBSTANCE USE DISORDER TREATMENT LANDSCAPE 2020: CLIENT-LEVEL AND FACILITY-LEVEL FACTORS

Abstract Older adult substance use disorders (SUD) care requires specialized clinical practice. This poster reviews two datasets to emphasize client-level and facility-level factors (overall and state-by-state) relevant to older adult treatment programming, co-occurring disorders care, and days waiting for admission to treatment. The 2020 data from the National Survey of Substance Abuse Treatment Services (N-SSATS), administered by The Center for Behavioral Health Statistics and Quality (CBHSQ) of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, collects data from public/private SUD treatment facilities in the United States. Data from 16,066 facilities demonstrated only 24.7% of all facilities reported programming tailored for older adult care, with state-by-state analysis showing a range of 4.6% to 61.4% of treatment programs reporting older adult tailored care. The deficits of older adult programming availability are explained against the context of the 2020 Treatment Episode Dataset-Admissions (TEDS-A), administered by the CBHSQ, that examines admissions data from all 50 states, as well as the District of Columbia, U.S. territories, and Compact of Free Association (COFA) partners. The TEDS-A data consisted of 1,416,357 admissions, of which 11.8% (n=167,200) were aged 55 years-old or older. Of this older adult sample, 32.8% reported a co-occurring SUD and mental health disorder and 13.9% reported some number of days waiting to enter treatment. These (and other) client-level and facility-level factors (overall and state-by-state) will be used to emphasize specific needs for older adult SUD care.

Criminal Justice Referrals to Cannabis Use Disorder Treatment among Adolescents and Young Adults following Recreational Cannabis Legalization in the United States.

This study investigates whether the proportion of referrals to cannabis use disorder (CUD) treatment from the criminal justice system declined among adolescents (aged 12-17 years) and young adults (aged 18-24 years) following state recreational (adult use) cannabis legalization in the United States between 2008 and 2019. Cannabis use disorder treatment referral data were extracted from the Treatment Episode Dataset-Admissions and used to calculate trends in the number and proportion of criminal justice referrals. Difference-in-differences analysis was used to estimate the effect of recreational legalization on the state-level proportion of criminal justice referrals as a share of all admissions. Nationwide, the number and proportion of adolescent and young adult criminal justice referrals to CUD treatment declined over the study period. The proportion of young adult criminal justice referrals declined significantly more rapidly after recreational legalization as compared with before ( β = -0.045; 95% confidence interval, -0.079 to -0.010; P = 0.01). Among adolescents, the trajectory of decline in the proportion of criminal justice referrals did not change significantly following recreational legalization ( β = -0.033; 95% confidence interval, -0.073 to 0.008; P = 0.11). The decline in the proportion of young adult criminal justice referrals to CUD treatment following recreational legalization is likely due to falling cannabis-related arrests. Although cannabis criminalization may result in court-mandated CUD treatment for some young adults without CUD, the decline in CUD treatment admissions during a period of increasing CUD risk factors associated with recreational legalization represents a key health concern. Promoting screening and other CUD treatment referral sources, such as through primary care, may be warranted.

Opioid and stimulant attributed treatment admissions and fatal overdoses: Using national surveillance data to examine the intersection of race, sex, and polysubstance use, 1992–2020

BackgroundWe use national surveillance data to evaluate race/ethnicity by sex/gender differences and trends in substance use treatment admissions and overdose deaths involving opioid and stimulant use. MethodsWe used data (1992–2019) from the Treatment Episode Dataset-Admissions to identify treatment admissions and the Center for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (1999–2020) to identify overdose deaths. We assessed treatment admissions and related drug overdose deaths per 100,000 adults by sex and race/ethnicity for opioid and stimulant groups: cocaine, opioid, methamphetamines, cocaine and opioid use, cocaine and methamphetamines, and opioid and methamphetamines. ResultsWe found significant variations in treatment admissions and deaths by race/ethnicity and sex/gender. Cocaine-related treatment admissions and deaths were most prevalent among Non-Hispanic Black individuals over the study years, yet lower rates were evident among individuals from other racial/ethnic groups. Notably, Non-Hispanic Black men experienced larger increases in cocaine-only admissions than men of other racial/ethnic groups between 1992 and 2019. Men had higher opioid and stimulant treatment admissions and overdose deaths than women. We observed skyrocketing methamphetamine deaths among American Indian/Native Alaskan men and women from 1992 to 2019. DiscussionSteep increases in overdose deaths fueled by methamphetamines among Non-Hispanic Native Americans and cocaine among Non-Hispanic Black individuals suggest a need for more effective interventions to curb stimulant use. Variations by race/ethnicity and sex/gender also suggest interventions should be developed through an intersectionality lens.

Exploring the Impact of Adult‐use Cannabis Legalization on Legal System Referrals to Treatment for Cannabis Use: Do Age and Race Have a Moderating Effect?

PurposeDespite the progression of recreational cannabis legalization, the legal system remains the largest source of referral to treatment for cannabis use. The legal system's continued practice of requiring participation in cannabis treatment programs raises questions regarding the extent to which individuals who interact with the legal system are monitored for cannabis use post-legalization. This article presents trends in justice-system referrals to treatment for cannabis use in legal and nonlegal states for 2007–2019. The relationship between legalization and justice system treatment referrals for black, Hispanic/Latino, and white adults and juveniles was explored. Given that minority and youth populations are subject to disproportionate levels of cannabis enforcement, legalization is expected to have a weaker relationship with justice-system referral rates in white juveniles and black and Hispanic/Latino adults and juveniles compared to white adults. MethodsUsing 2007–2019 data from the Treatment Episode Data Set—Admissions (TEDS-A), variables were created for state-level rates of legal system–referred treatment admissions for cannabis use in black, Hispanic/Latino, and white adults and juveniles. Rate trends were compared across populations and staggered difference-in-difference and event analyses were conducted to determine whether legalization is associated with a decline in justice-system referrals to treatment for cannabis use . FindingsFor the study period, the mean rate of legal system–referred admissions in the total population was 2.75 per 10,000 residents. Black juveniles had the highest mean rate (20.16), followed by Hispanic/Latino juveniles (12.35), black adults (9.18), white juveniles (7.58), Hispanic/Latino adults (3.42), and white adults (1.66). Legalization did not have a significant impact on treatment-referral rates in any population of study. Events analyses indicated significant rate increases in black juveniles in legalized states compared to controls at 2 and 6 years after policy change, and in black and Hispanic/Latino adults at 6 years after policy change (all, P < 0.05). While racial/ethnic disparities in referral rates declined in absolute terms, the relative size of these disparities increased in legalized states. ImplicationsTEDS-A captures only publicly funded treatment admissions and relies on the quality of individual-state reporting. Individual-level factors that may impact decisions regarding treatment referrals for cannabis use could not be controlled for. Despite limitations, the present findings suggest that for individuals who interact with the criminal legal system, cannabis use may still result in legal monitoring after reform. The upward trend in legal system referrals for black (but not white) adults and juveniles several years after states legalize cannabis warrants further examination and may reflect continued disparate treatment of these populations at multiple points along the legal-system continuum.

The trend of characteristics and pattern of polysubstance co-occurrences among pregnant women: TEDS-A findings

ABSTRACT Objective The study’s objectives were (i) demonstrating the trends of sociodemographic, substance use, and clinical characteristics of pregnant women admitted to substance use treatment facilities from 2011 to 2018 and (ii) mining their patterns of association of polysubstance use. Methods We used the Treatment Episode Data Set – Admissions (TEDS-A) of pregnant women between 2011 and 2018. The Cochran–Armitage test was employed to test the trend, and Market Basket Analysis (MBA) was used for mining association rules to identify polysubstance use patterns. Results Over the years, some cohorts consistently showed majority admissions. Among these, age (30–39 years), education (12 or more years), injection as a route, and medication-assisted opioid therapy showed a significantly increasing trend. Admissions increased significantly with heroin (66%) and methamphetamine (46%) and decreased between 23% and 43% with alcohol, marijuana/hashish, cocaine/crack, other opiates/synthetics, and benzodiazepines. Basket analysis revealed some patterns of polysubstance co-occurrence consistent over the years. For instance, the co-occurrences of {alcohol, marijuana/hashish} or {methamphetamine, marijuana/hashish} were the most common. Conclusions The findings on trends and long-run polysubstance use patterns may help to find pregnant women’s most vulnerable cohorts for effective interventions to minimize the health risk for them and their fetuses.

State level variation in substance use treatment admissions among criminal legal-referred individuals

BackgroundIndividuals involved in the criminal legal system face unique challenges to accessing substance use disorder (SUD) treatment, yet state-level variation in referrals for treatment remains largely unknown. To address disparities in the overdose crisis among individuals with criminal legal involvement, it is important to understand variation in SUD treatment across states. MethodsWe conducted a retrospective comparison of substance use treatment referrals from the criminal legal system and other sources across participating states. Using data from the 2018–2019 Treatment Episode Dataset-Admissions, we characterized treatment referral rates from the criminal legal system, the substances most commonly leading to treatment, and rates of treatment with medication for opioid use disorder (MOUD) across states. ResultsAcross all states, criminal legal referral rates were higher than non-criminal legal rates. Criminal-legal referral rates, adjusted for state overdose deaths, were highest in the Northeast and Midwest. Methamphetamine use was the most common substance leading to treatment referral from the criminal legal system in 24 states while opioid use was the most common reason for non-criminal legal referrals in 34 states. In over half the states analyzed, fewer than 10% of opioid treatment referrals from the criminal legal system received MOUD. In almost all states, MOUD was more common in treatment referred from non-criminal legal settings. ConclusionState-specific policies and practices shape drug policy and the SUD treatment landscape for people with criminal legal involvement. Standards and ongoing monitoring for substance use treatment referrals from the criminal-legal system should be considered by federal agencies charged with addressing the ongoing overdose crisis.

Association Between Medicaid Managed Care Coverage of Substance Use Services and Treatment Utilization

Medicaid insures a disproportionate share of adults with substance use disorder (SUD) and is thus uniquely positioned to facilitate access to care. Many enrollees receive coverage through Medicaid managed care (MMC) plans, which receive capitated payments in exchange for coverage of a defined set of benefits. Historically, coverage of substance use services has been carved out of MMC plans and financed fee-for-service (FFS) by state Medicaid programs, but in recent years, many states have opted to carve in this benefit. Little is known about whether MMC coverage of substance use services, relative to FFS coverage, is associated with changes in utilization. To examine the association between changes in MMC coverage of substance use services and admissions for substance use treatment. This cross-sectional study examined changes in admissions for substance use treatment in 2 states after coverage of substance use services was either carved into (Nebraska) or carved out of (Maryland) comprehensive MMC coverage. Synthetic control methods were used to compare changes in admissions between states that did and did not alter MMC coverage of substance use services. Data on substance use treatment admissions were obtained from the Treatment Episode Data Set-Admissions from 2010 to 2019. Carve-outs or carve-ins of coverage for both inpatient and outpatient substance use services from comprehensive MMC coverage. Reported substance use treatment admissions per 100 000 residents and admissions by treatment type (ie, rehabilitation or residential, outpatient, and detoxification) per 100 000 residents. Maryland's carve-out was associated with an additional mean 787.1 (95% CI, 624.6-1141.7) substance use admissions per 100 000 residents during 2015 and 2016, a relative increase of 104.4% (95% CI, 64.4%-154.1%) compared with its synthetic control. This increase was concentrated among changes in outpatient services utilization. In Nebraska, the carve-in was associated with a mean decrease of 97.2 (95% CI, -23.4 to 213.6) admissions per 100 000 residents, a relative decrease of 33.2% (95% CI, -54.1% to 29.6%) compared with its synthetic control and was concentrated primarily among admissions for detoxification services. The results of this cross-sectional study suggest that carving out coverage of substance use services and financing them through FFS coverage may be associated with overall increases in treatment utilization but with heterogeneous associations across states and treatment types.

Historical Trends in Veteran Community Substance Use Treatment: 2000–2019

Background: Substance use is a significant health crisis for the Veteran population. Prior research has thoroughly examined Veteran substance use within Veterans Health Administration (VHA) settings. However, such data tends to be outdated, and there is minimal research on substance use services delivered outside of VHA systems. This study examines historical patterns of Veteran substance use using a large sample of community-based substance-use treatment admissions. Methods: Data were drawn from the Substance Abuse and Mental Health Data Archive Treatment Episode Data Set-Admissions. Of the 39,425,886 total admissions between 2000 and 2019, 1,361,339 were of Veterans. Analyses compared Veteran versus non-Veteran admissions on demographics and historical trends in nature of substance-use admissions. Results: Relative to non-Veterans, Veteran admissions were more likely to be prompted by alcohol use. Over time, heterogeneity in substances prompting admissions has increased dramatically for both Veterans and non-Veterans, with particularly notable increases in opiate and stimulant use. Conclusion: Results suggest Veterans admitted to community substance-use treatment are unique relative to their non-Veteran peers. Development and implementation of treatments to target a range of substances while also considering the environmental challenges (e.g., homelessness) commonly faced by this population appear essential to best servicing community-based Veterans.

Admissions to substance use treatment facilities for cannabis use disorder, 2000-2017: Does legalization matter?

A growing number of US states have legalized marijuana use in the past decade. We examined if marijuana legalization is associated with increased marijuana-related admissions to substance use treatment facilities between 2000 and 2017. Data from the Treatment Episode Data Set-Admissions were used to examine the relationship between marijuana-related admissions among adults aged ≥18 by year and legalization status (i.e., fully legalized, medical use only [partially legalized], and illegal) (N = 35,457,854). Using interaction analyses, we further examined whether certain patient characteristics were associated with residence in states that legalized marijuana use as compared to those in which marijuana remained illegal. Overall, the proportion of marijuana-related admissions in states with legalization decreased by 2.3% from 31.7% in 2000-2005 to 29.4% in 2012-2017 (odds ratio [OR], 0.90; 95% confidence intervals [CI], 0.89-0.90) with little difference from states where marijuana use remained illegal, in which marijuana use as any reason for admissions decreased by 0.3% from 39.8% in 2000-2005 to 39.5% in 2012-2017 (OR, 0.99; 95% CI, 0.98-0.99). We did not find any striking patient characteristics (e.g., referral by the police) associated with admissions in states that legalized compared to those that had not. While earlier studies suggested that marijuana legalization is associated with increased levels of use, emergency department visits, and traffic fatalities, our findings suggest that marijuana legalization did not increase marijuana-related treatment use in the United States. This is the first study to examine the association of marijuana legalization with marijuana-related treatment use.

A longitudinal cross-sectional analysis of substance use treatment trends for individuals experiencing homelessness, criminal justice involvement, both, or neither - United States, 2006-2018

SummaryBackgroundIndividuals experiencing homelessness or criminal justice involvement (CJI) have higher rates of substance use than the general public. Despite documented barriers to accessing treatment, few studies have compared substance use treatment patterns between these groups.MethodsThis paper uses data from the Treatment Episode Dataset-Admissions between 2006 to 2018 to describe characteristics and trends in substance use treatment admissions indicating homelessness (n=2,524,413), CJI (4,764,750), both (509,902), or neither (8,950,797) in the United States. We used multivariable logistic regression to examine trends independent of demographic differences between groups.FindingsBetween 2006 and 2018, the proportion of treatment admissions related to heroin increased across all groups. Methamphetamine-related admissions rose substantially for individuals experiencing homelessness, CJI, or both. By 2018, 27·8% (95% CI: 27·4-28·2%) of admissions for individuals experiencing both were methamphetamine-related and 16·7% (95% CI: 16·3-17·0%) were heroin-related. Conversely, among individuals experiencing neither, 7·5% (95% CI: 7·4-7·5%) of admissions were methamphetamine-related and 33·6% (95% CI: 33·4-33·7%) were heroin-related. Individuals experiencing both homelessness and CJI received lower rates of medications for opioid use disorder (OUD) (8·3%; 95% CI: 8·2-8·3%) compared to individuals experiencing neither (36·4%; 95% CI: 36·4-36·4%).InterpretationCommunity treatment facilities should be supported to provide medications for OUD and accommodate rising rates of methamphetamine and polysubstance-related treatment admissions in populations experiencing complex social drivers of health such as homelessness, CJI, or both.FundingNational Institute of General Medical Sciences and National Institute of Diabetes and Digestive and Kidney Diseases.

U.S. older adults’ heroin and psychostimulant use treatment admissions, 2012–2019: Sociodemographic and clinical characteristics

BackgroundIncreases in U.S. older adults’ nonprescription opioid and psychostimulant use call for examining their treatment admissions for these substances. MethodsUsing admissions age 55 + involving heroin (N = 299,073) from the 2012–2019 Treatment Episode Data Set-Admissions, we examined trends and sociodemographic and clinical characteristics of three groups: (1) heroin-only admissions (i.e., not involving cocaine or methamphetamine), (2) heroin-cocaine admissions, and (3) heroin-methamphetamine admissions. Bivariable and multivariable logistic regression analyses were conducted to examine the research questions. ResultsBetween 2012 and 2019, the numbers of both heroin-only and heroin-cocaine admissions increased 2.3-fold and heroin-methamphetamine admissions increased seven-fold. First time heroin-methamphetamine admissions increased 18-fold. Heroin-methamphetamine admissions were concentrated in the Western region and heroin-cocaine admissions in the Northeastern region. Multivariable analyses showed a nearly 6 times higher relative risk ratio (RRR; 95% CI=5.24–6.74) for heroin-methamphetamine vs. heroin-only admissions in 2019 compared to 2012. Being non-Hispanic Black, compared to non-Hispanic White, was associated with a RRR of 2.4 (95% CI=2.34–2.46) for heroin-cocaine admissions and a RRR of 0.14 (95% CI=0.12–0.15) for heroin-methamphetamine admissions. Late-onset heroin use, experience of homelessness and other psychiatric problems, and past 30-day arrest episodes were associated with a higher likelihood of heroin-cocaine and heroin-methamphetamine admissions, while injection drug use (IDU) was associated with a higher likelihood of heroin-methamphetamine admissions only. ConclusionsHealthcare providers should assess and monitor psychostimulant, methamphetamine in particular, use among older adults. Those who use heroin and psychostimulants should receive substance use treatment and help to secure stable housing and meet other living needs.