Untreated Substance Use Research Articles

Staff perspectives of barriers and facilitators to implementation of the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in New York City safety net hospitals

BackgroundIn response to the heavy burden of untreated substance use disorders (SUD) in hospital patients, many health systems are implementing addiction consult services staffed by interprofessional teams that diagnose SUD, make recommendations for SUD care in the hospital, and link patients to post-discharge treatment. In 2018, the New York City public hospital system began rolling out the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in six hospitals. CATCH teams are comprised of an addiction-trained medical provider, social worker or addiction counselor, and peer counselor. MethodsThe study conducted qualitative interviews with CATCH staff at all six participating hospitals as part of a pragmatic trial studying the effectiveness and implementation of CATCH. The Consolidated Framework for Implementation Research (CFIR) framework guided interviews conducted from 2018 to 2021 with 26 staff at the start of implementation and with 33 staff 9–12 months post-implementation. The study team created a codebook a priori and further refined it through additional coding of initial interviews. Codes were systematically analyzed using the CFIR. ResultsBarriers and facilitators spanned four CFIR domains: inner setting, outer setting, process, and individual characteristics. Barriers identified were primarily related to the outer and inner settings, including patient characteristics and limited resources (e.g. medical comorbidities, homelessness), insurance, CATCH team role confusion, and infrastructure deficits (e.g., availability of physical space). Additional barriers related to process (workload burden), and characteristics of individuals (stigma and lack of comfort treating SUD among medical teams). Facilitators were mostly related to the characteristics of individuals on the CATCH team (advantages and expertise of the CATCH peer counselor, CATCH team communication and cohesiveness) and inner setting (CATCH team relationships with hospital staff, hospital leadership buy-in and support, and infrastructure). Community networks (outer setting) and CATCH training resources (process) were also facilitators of program implementation. ConclusionAddiction consult services have great potential for improving care for hospital patients with SUD, but as new programs in busy hospital settings they face barriers to implementation that could impact their effectiveness. Barriers may be particularly impactful for programs operating in safety-net hospitals, given limited resources within the health system and the multiple and complex needs of their patients. Understanding the strengths of these programs as well as the barriers to their implementation is critical to utilizing addiction consult services effectively.

Policies Affecting Pregnant Women with Substance Use Disorder

Policies Affecting Pregnant Women with Substance Use Disorder

Untreated substance use disorder affects glycemic control: Results in patients with type 2 diabetes served within a network of community-based healthcare centers in Florida.

Patients with diabetes and comorbid substance use disorders (SUD) experience poor diabetes management, increased medical complications and mortality. However, research has documented that patients engaged in substance abuse treatment have better management of their comorbid conditions. The current study examines diabetes management among patients with type 2 diabetes, with and without comorbid SUD, receiving care at Florida-based Federally Qualified Health Centers (FQHC) of Health Choice Network (HCN). A retrospective analysis was conducted using deidentified electronic health records of 37,452 patients with type 2 diabetes who received care at a HCN site in Florida between 2016 and 2019. A longitudinal logistic regression analysis examined the impact of SUD diagnosis on achievement of diabetes management [HbA1c < 7.0% (53 mmol/mol)] over time. A secondary analysis evaluated, within those with an SUD diagnosis, the likelihood of HbA1c control between those with and without SUD treatment. The longitudinal assessment of the relationship between SUD status and HbA1c control revealed that those with SUD (N = 6,878, 18.4%) were less likely to control HbA1c over time (OR = 0.56; 95% CI = 0.49-0.63). Among those with SUD, patients engaged in SUD treatment were more likely to control HbA1c (OR = 5.91; 95% CI = 5.05-6.91). Findings highlight that untreated SUD could adversely affect diabetes control and sheds light on the opportunity to enhance care delivery for patients with diabetes and co-occurring SUD.

Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers

This study aimed to determine the prevalence of treated and untreated substance use disorders among Medicare beneficiaries, the characteristics of Medicare beneficiaries with substance use disorders, and reasons for their unmet needs. This study used data from the National Survey of Drug Use and Health, 2015-2019. Substance use disorder was defined based on DSM-IV dependence or abuse criteria. Descriptive analyses were conducted in 2021, including testing for differences in unadjusted means. Approximately 1.7 million Medicare beneficiaries were estimated to have past-year substance use disorder (8% of Medicare beneficiaries aged <65 years and 2% aged ≥65 years). Overall, 77% had an alcohol use condition, 16% had a prescription drug use condition, and 10% had a marijuana use condition. Of those who had past-year substance use disorder, 11% received treatment for their condition. Common reasons for not receiving treatment were lack of motivation (41%), financial barriers (33%), concern about what others might think (24%), logistical barriers such as lack of transportation (21%), and uncertainty about treatment efficacy (13%). Medicare beneficiaries with substance use disorders were more than twice as likely to have past-year serious psychological distress as those without substance use disorders (44% vs 21%, p<0.001 for those aged <65 years; 14% vs 4%, p<0.001 for those aged ≥65 years). Percentages of past-year suicidal ideation were also much higher among Medicare beneficiaries with substance use disorders than without (24% vs 6%, p<0.001 for those aged <65 years; 7% vs 2%, p=0.006 for those aged ≥65 years). Few Medicare beneficiaries who need substance use disorder treatment receive it. Reducing Medicare coverage gaps and stigma may help meet this need.

The harms of punishing substance use during pregnancy

As rates of substance use have increased in the United States, rates of substance-involved pregnancies have also been on the rise, inspiring new civil policies designed to punish pregnant and parenting individuals who engage in substance use or are living with an untreated substance use disorder. Proponents of punitive civil policies argue that such policies will deter substance use behaviors and/or that substance use during pregnancy deserves punishment for harming the fetus. Current scientific evidence invalidates both claims, offering compelling evidence that punitive civil policies often worsen the harms of substance use for both parent and child. In this commentary, we review this evidence and explain how punitive policies that threaten child removal and the termination of parental rights exacerbate the very problems they are ostensibly designed to reduce. Rather than coercive and punitive responses, families affected by substance use need greater access to affordable, evidence-based treatment as well as services that address the structural and relational concerns underlying substance use. Above all, responses to perinatal substance use in both policy and practice should prioritize keeping families together.

Infant neurodevelopmental outcomes of prenatal opioid exposure and polysubstance use

BackgroundPrenatal opioid exposure has been linked to adverse birth outcomes and delays in infant development. Existing literature is limited by a simple group-differences approach as well as inadequate controls for sociodemographic factors and polysubstance exposure co-occurring with prenatal opioid use. MethodThe current study assessed cumulative opioid exposure (duration of prescribed and illicit opioid use) as a predictor of infant birth outcomes and mother-reported developmental status at three and six months of age, controlling for polysubstance exposure. Participants were predominantly low-income pregnant and peripartum women, oversampled for mothers receiving medication-assisted treatment (MAT) for opioid use disorder. Prenatal opioid and non-opioid substance use were reported by mothers using a Timeline Follow-Back Interview completed during the third trimester and updated postnatally (infant age six months). ResultsDevelopmental scores were in the normal range. However, total opioid exposure was positively related to premature birth and inversely related to mother-reported developmental status in specific domains. Associations with three-month fine motor skills and six-month communication skills were robust to controls for polysubstance exposure and sociodemographic covariates. ConclusionsResults suggest unique effects of prenatal opioid exposure on the early development of fine motor and communication skills. Similar findings were obtained for prescribed and illicit opioid use, underscoring developmental risks of both MAT and untreated substance use. Exploratory analyses investigating type and timing of MAT suggest directions for future research.

Impact of Extended Access Methamphetamine, Cocaine, and MDPV Self‐administration on Recognition Memory in Rats

Over 18 million people in the United States alone are classified as having an untreated substance use disorder. Given that substance use disorders are chronic by nature, with significant negative impacts on quality of life, it is crucial to gain a better understanding of the consequences of prolonged use in an effort to prevent or reverse deficits in afflicted individuals. Regarding stimulants, monoamine releasers (e.g., methamphetamine) rather than monoamine uptake inhibitors (e.g., cocaine) are associated with greater degrees of neurodegeneration and neuroinflammation, often linked to deficits in memory, psychosis, and loss of impulse control. Interestingly, recent data suggest that MDPV, a synthetic cathinone and monoamine uptake inhibitor, has neurotoxic effects; however, the neurocognitive consequences of MDPV self-administration remain largely unexplored. The current study aimed to directly compare the neurocognitive impacts (deficits in novel object recognition assay [NOR]) in rats (n=8/group) with short- (90-min) or extended- (12-h) access to MDPV (0.032 mg/kg/inf), methamphetamine (0.1 mg/kg/inf), or cocaine (0.32 mg/kg/inf) self-administration; grain pellets were also available throughout the sessions for responding on the alternate lever. Self-administration sessions were conducted five days per week to allow for other behaviors to be evaluated in a drug-free state. NOR was conducted four times, once prior to any drug self-administration history, after 3 and 6 weeks of drug self-administration, and once more following a 3-week drug-free period. To conduct NOR, rats were habituated in the testing arena for 30-min. 24-h later, two identical objects were placed in the arena and rats could explore the objects for 5-min (training). One hour after training, one of the previously explored objects along with a novel object were placed in the arena and rats were allowed to explore the objects for 3-min (testing). Object exploration was defined as the rat's head being within 2 cm of the object without biting it. Rats that had extended access to MDPV or methamphetamine exhibited time-dependent deficits in the novel object recognition assay relative to rats given access to saline. No deficits were observed in rats with extended access to cocaine. Furthermore, rats showed no deficits in recognition memory following short access to any reinforcer. The total exploration time of objects remained comparable among all groups. These data suggest that unlike cocaine, the prototypical monoamine uptake inhibitor, MDPV is capable of producing memory deficits often associated with neuroinflammation and/or neurodegeneration. Future studies will evaluate markers of neurodegeneration and neuroinflammation in these rats and explore pharmacological avenues to mitigate stimulant-induced neurocognitive deficits.

Revision of §64 of the German Penal Code from a psychiatric perspective-Position paper of a task force of the German Association for Psychiatry, Psychotherapy and Psychosomatics

In Germany every second offence occasioning bodily harm and every fourth sexual offence occur under the influence of alcohol or drugs. Untreated substance use disorders are a risk factor for further offences. The §64 of the German Penal Code (StGB) regulates the commitment of offenders to a Forensic addiction treatment unit as a result of an addiction to excessive consummation of intoxicating substances. The previous regulation has come under criticism because too many patients are committed, the sentence is often given to the wrong persons, the treatment is often terminated without success and the sentence consumes to many resources. From a psychiatric perspective the reform of commitment to a Forensic addiction treatment unit (§64 StGB) must fulfil the principles of medical ethics, in particular the respect for the autonomy of the patient, the principle of distributional justice and the code of medical professional ethics. The commitment according to §64 must be restricted to the treatment of people with a clinically relevant substance use disorder. From a psychiatric perspective, decisive for the prospect of success are the willingness to be treated and self-determination for admission to the clinic. In order to release the treatment from the extrinsic influences of the enforcement law, on admission to treatment a sufficient amount of the sentence should have already been served that the commitment only serves the purpose of the treatment and resocialization, so that the risk of further substance-related offences is reduced. The legal term "Entziehungsanstalt" should be replaced by "Forensic Clinic for Dependancy Diseases".

Addressing the Epidemic: Screening for Substance Use in Pregnancy [04K

INTRODUCTION: The purpose of this project was to implement the use of an evidence-based model and validated screening tool for high-risk substance use in pregnancy. Substance use among pregnant women has quadrupled. Unidentified and untreated substance use can lead to poor maternal/ fetal outcomes and is currently the leading cause of maternal death in the U.S. METHODS: With IRB approval, 65 pregnant women were screened for substance use with a validated screening tool and provided brief intervention and/or referral to treatment as indicated. Data was collected over an 8-week period and analyzed using SPSS. RESULTS: Screening revealed that 61.4% of the women reported substance use (alcohol use, tobacco use, non-medical prescription drug use, or illicit drug use) in the past year. Continued substance use after knowledge of pregnancy was reported by 0% for alcohol use, 18.5% for tobacco use, 1.5% for non-medical prescription drug use, and 10.7% for illicit drug use. Screening indicated that 7.7% of the women had moderate to high-risk illicit drug use and all these women received a brief intervention and were referred for treatment. The project results were compared to the average substance use in pregnancy reported by local and recent literature data which included: 5.5-8.5% with alcohol use, 13.2-15.9% with tobacco use, and 6-7.7% with illicit drug/non-medical prescription drug use. CONCLUSION: This project confirms that substance use in pregnancy is an ongoing health issue and supports recommendations from the leaders in obstetrics and addiction medicine for universal substance use screening in all women of reproductive age.

Neurocognitive Deficits Associated with Methamphetamine, Cocaine, and MDPV Self‐administration in Rats

Over 18 million people in the United States alone are classified as having an untreated substance use disorder. Given the chronicity associated with a substance use disorder, it is crucial to gain a better understanding of the toxicity associated with prolonged use in an effort to prevent or reverse deficits in afflicted individuals. In the context of stimulant abuse, monoamine releasers (e.g., methamphetamine) rather than monoamine uptake inhibitors (e.g., cocaine) are typically associated with neurodegeneration and neuroinflammation that have been linked to deficits in memory, psychosis, and loss of impulse control. Interestingly, recent data suggest that the synthetic cathinone MDPV (a monoamine uptake inhibitor) is able to induce neurotoxicity but the neurocognitive consequences of MDPV self‐administration remain largely unexplored. The current study aims to investigate the degree to which self‐administered MDPV can induce deficits in recognition memory compared to more classical stimulants (e.g., methamphetamine and cocaine). Following catheter implantation, male Sprague‐Dawley rats were allowed to respond on a lever for grain pellets in 90‐min sessions for 14 days. Sessions were then extended to 12‐h wherein rats could respond for grain pellets on one lever and an infusion of either 0.032 mg/kg MDPV, 0.1 mg/kg methamphetamine, 0.32 mg/kg cocaine, or saline on the other lever (n=7–8/group). Self‐administration sessions were conducted five days per week to allow for other behaviors to be evaluated in a drug‐free state. The novel object recognition assay was utilized to evaluate hippocampal‐dependent recognition memory prior to the first self‐administration session and reevaluated after thirty self‐administration sessions. To evaluate recognition memory, rats were habituated in the testing arena for 30‐min. 24‐h later, two identical objects were placed in the arena and rats could explore the objects for 5‐min (training). One hour after training, the previously explored object along with a new object were placed in the arena and rats were allowed to explore the objects for 3‐min (testing). Object exploration was defined as the rat’s head being within 2 cm of the object without biting it. MDPV, methamphetamine, cocaine, and grain pellets (in the saline group) all maintained robust levels of self‐administration. Rats that had self‐administered MDPV or methamphetamine exhibited deficits in recognition memory relative to rats given access to saline. No deficits were observed in animals that had previously self‐administered cocaine. The total exploration time of objects remained comparable among all groups. These data suggest that despite being a monoamine uptake inhibitor, MDPV is able to induce deficits in memory that are likely caused by neuroinflammation and/or neurotoxicity. Future studies will evaluate markers of neurodegeneration and neuroinflammation in these animals and explore pharmacological avenues to mitigate stimulant‐induced neurocognitive deficits.Support or Funding InformationSupported by NIH grant R01DA039146 and the NIH IRPs of NIDA and NIAAA.

Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: A qualitative longitudinal study

Untreated substance use disorders remain a pervasive public health problem in the United States, especially among medically-underserved and low-income populations, with opioid and alcohol use disorders (OAUD) being of particular concern. Primary care is an underutilized resource for delivering treatment for OAUD, but little is known about the organizational capacity of community-based primary care clinics to integrate treatment for OAUD. The objective of this study was to use an organizational capacity framework to examine perceived barriers to implementing the continuum of care for OAUD in a community-based primary care organization over three time points: pre-implementation (preparation), early implementation (practice), and full implementation. Clinic administrators and medical and mental health providers from two clinics participated in interviews and focus groups. Barriers were organized by type and size, and are presented over the three time points. Although some barriers persisted, most barriers decreased over time, and respondents reported feeling more efficacious in their ability to successfully deliver OAUD treatment. Findings contribute to the needed literature on building capacity to implement OAUD treatment in primary care and suggest that while barriers may be sizable and inevitable, successful implementation is still possible.

Family substance use screening: less to hide, more to gain.

A relentless rise in undertreated or untreated substance use disorders highlights the magnitude of the challenge the society is facing and a critical need to identify evidence-based, practical approaches in order to effectively screen people at high risk for unhealthy alcohol use, tobacco and drug use, increase early detection of substance use disorders, and offer the proper care they need. The Family CAGE (an acronym of four questions on alcohol use) is a brief questionnaire adapted from the original CAGE questionnaire devised by Frank et al1 and studied by Basu et al2, in this issue under a format encompassing drug use (AID=Adapted to Include Drugs). The study examines the validity and associated characteristics of the questionnaire for the diagnosis of alcohol and other substance use disorders as well as the inter-rater reliability between one family member and the substance user. The results were drawn from a cross-sectional analysis of two samples: treatment seeking substance-using patients, and individuals receiving outpatient psychiatric treatment while not pursuing treatment for substance use disorders. In both groups, the scores of the Family CAGE-AID and the traditional CAGE-AID questionnaires were significantly correlated. In the psychiatric sample, a correlation between the scores of the questionnaire and ICD-10 symptom score was observed, along with a moderate but significant agreement between the scores of substance users and family members. Family CAGE-AID was found to be sensitive and specific for the diagnosis of substance dependence formulated using ICD-10 criteria2. There are a few points to consider. Because of the design of the study, family members’acceptance of the questions about other members’ alcohol and drug use problems is unknown, which needs further study. The authors acknowledged that a limited range of substance use diagnoses and disease severity in the study sample limited the generalizability of study findings, and that psychiatric evaluation was not performed to control for the quality of responses among participating relatives. However, the findings demonstrate the practicality and potential utility of a family screen instrument for alcohol and drug use problems. Among future applications, the involvement of multiple family members in the interview, and confirmation studies in large samples at the primary care level and within different age ranges should be considered. Following evaluation, data gathered on interventions outcome and follow up assessment will be of interest.

The Critical Link Between Health Care And Jails

As a group, jail-involved individuals, which we define here as people with a history of arrest and jail admission in the recent past, carry a heavy illness burden, with high rates of infectious and chronic disease as well as mental illness and substance use. Because these people have tended to also be uninsured, jail frequently has been their only regular source of health care. Three thousand three hundred local and county jails processed 11.6 million admissions during the twelve-month period ending midyear 2012. The Urban Institute estimated as much as 30 percent of some local corrections budgets is allocated to inmate health care services. This investment is largely lost when people are released back into the community, where they typically do not get treatment. For people with untreated substance use or mental illness, this issue reaches beyond public health, because without treatment, these people are at heightened risk of cycling into and out of jail for low-level, nonviolent offenses. This article offers eight policy recommendations to build a continuum of care that will ensure that jail-involved people get the care they need, regardless of where they reside. With the expansion of Medicaid eligibility under the Affordable Care Act, there is now a critical opportunity to bring the jail-involved population into the mainstream health care system, which benefits the health care and criminal justice systems and society at large.

Challenges and Opportunities for Integrating Preventive Substance-Use-Care Services in Primary Care through the Affordable Care Act

Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-harmful public health problem in the United States, particularly in medically underserved and low-income populations lacking access to appropriate treatment. The need for greater access to SUD treatment was expressed as policy in the Final Rule on standards related to essential health benefits, required to be covered through the 2010 Affordable Care Act (ACA) health insurance exchanges. SUD treatment services have been included as an essential health benefit, in a manner that complies with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Consequently, with the ACA, a vast expansion of SUD-care services in primary care is looming. This commentary discusses challenges and opportunities under the ACA for equipping health care professionals with appropriate workforce training, infrastructure, and resources to support and guide science-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) for SUD in primary care.

Reaching Soldiers with Untreated Substance Use Disorder: Lessons Learned in the Development of a Marketing Campaign for the Warrior Check-Up Study

The Warrior Check-Up, a confidential telephone-delivered intervention, is designed to reach active-duty soldiers with untreated substance-use disorder at a large US military base. This paper describes the development and successful implementation of the study's marketing strategies at the recruitment period's midpoint (2010–2012). Qualitative analyses of focus groups (n = 26) and survey responses (n = 278) describe the process of campaign design. Measures of demographics, media exposure, post-traumatic stress, anxiety and depression gathered from callers (n = 172) are used in quantitative analysis assessing the campaign's success in reaching this population. Implications, limitations, and suggestions for future research are discussed. Department of Defense provided study funding.

Integrating Substance Abuse Treatment Into HIV Care

Untreated substance use disorders (SUD) among HIV patients contribute to worse HIV care outcomes and increased HIV transmission. Although there are clinical and policy recommendations for integrated SUD and HIV treatment, payment issues including complex funding streams are a barrier. We assessed the availability of guideline-concordant medication-assisted therapies to treat alcohol, tobacco, and opioid dependence on state-administered AIDS Drug Assistance Programs (ADAPs), an important source of drug coverage for low-income HIV patients. We examined which medication-assisted therapies are most likely to be included on formularies and variation of these therapies across states. We reviewed state-specific ADAP formularies from 1997 to 2009 for the presence of guideline-concordant medication-assisted therapies to treat alcohol, tobacco, and opioid dependence. The most frequently included medication-assisted therapies were those to treat tobacco dependence, followed by opioid dependence. Few states covered alcohol dependence medications. In each year, <10% of states covered all recommended medications and <50% covered a partial formulary for at least 1 SUD. ADAPs could provide access to medication-assisted therapies for SUD for a significant number of HIV patients, but these medications have not been widely covered throughout the program's history. Increased availability of medication-assisted therapies through ADAP could facilitate integrated HIV and SUD care.

Early data from project engage: a program to identify and transition medically hospitalized patients into addictions treatment

BackgroundPatients with untreated substance use disorders (SUDs) are at risk for frequent emergency department visits and repeated hospitalizations. Project Engage, a US pilot program at Wilmington Hospital in Delaware, was conducted to facilitate entry of these patients to SUD treatment after discharge. Patients identified as having hazardous or harmful alcohol consumption based on results of the Alcohol Use Disorders Identification Test-Primary Care (AUDIT-PC), administered to all patients at admission, received bedside assessment with motivational interviewing and facilitated referral to treatment by a patient engagement specialist (PES). This program evaluation provides descriptive information on self-reported rates of SUD treatment initiation of all patients and health-care utilization and costs for a subset of patients.MethodsProgram-level data on treatment entry after discharge were examined retrospectively. Insurance claims data for two small cohorts who entered treatment after discharge (2009, n = 18, and 2010, n = 25) were reviewed over a six-month period in 2009 (three months pre- and post-Project Engage), or over a 12-month period in 2010 (six months pre- and post-Project Engage). These data provided descriptive information on health-care utilization and costs. (Data on those who participated in Project Engage but did not enter treatment were unavailable).ResultsBetween September 1, 2008, and December 30, 2010, 415 patients participated in Project Engage, and 180 (43%) were admitted for SUD treatment. For a small cohort who participated between June 1, 2009, and November 30, 2009 (n = 18), insurance claims demonstrated a 33% ($35,938) decrease in inpatient medical admissions, a 38% ($4,248) decrease in emergency department visits, a 42% ($1,579) increase in behavioral health/substance abuse (BH/SA) inpatient admissions, and a 33% ($847) increase in outpatient BH/SA admissions, for an overall decrease of $37,760. For a small cohort who participated between June 1, 2010, and November 30, 2010 (n = 25), claims demonstrated a 58% ($68,422) decrease in inpatient medical admissions; a 13% ($3,308) decrease in emergency department visits; a 32% ($18,119) decrease in BH/SA inpatient admissions, and a 32% ($963) increase in outpatient BH/SA admissions, for an overall decrease of $88,886.ConclusionsThese findings demonstrate that a large percentage of patients entered SUD treatment after participating in Project Engage, a novel intervention with facilitated referral to treatment. Although the findings are limited by the retrospective nature of the data and the small sample sizes, they do suggest a potentially cost-effective addition to existing hospital services if replicated in prospective studies with larger samples and controls.

Massachusetts’s Experience Suggests Coverage Alone Is Insufficient To Increase Addiction Disorders Treatment

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

Adaptations across Clinical Sites of an Integrated Treatment Model for Persons with HIV and Substance Abuse

Substance use disorders are common among people living with HIV (PLWHA), and PLWHA with untreated substance use are less likely to receive antiretroviral therapy (ART) or achieve viral suppression when ART is prescribed. Integrated behavioral and medical interventions are one approach used to treat complex chronic illnesses, including HIV and substance abuse (SA). As the potential benefit for integrated HIV-substance abuse treatment is recognized, the number of providers attempting to integrate care is growing. Integrated care models can range from coordinated to colocated to fully integrated models. Providers need a better understanding of these implementation options for HIV-substance abuse treatment and how they impact providers of different disciplines. Between April and November 2006, interviews exploring the process of implementing an integrated HIV-substance abuse intervention were completed with clinic staff at three diverse HIV clinics in North Carolina. Key differences in implementation between sites were found. The degree of integrated care between sites ranged from colocated to integrated, and clinic staff perceived each integrated model to have advantages and disadvantages. Recommendations for implementing HIV-SA integrated care are made.

How Are Substance Use Disorders Addressed in VA Psychiatric and Primary Care Settings? Results of a National Survey

This study examined interventions for substance use disorders within the Department of Veterans Affairs (VA) psychiatric and primary care settings. National random samples of 83 VA psychiatry program directors and 102 primary care practitioners were surveyed by telephone. The survey assessed screening practices to detect substance use disorders, protocols for treating patients with substance use disorders, and available treatments for substance use disorders. Respondents reported extensive contact with patients with substance use problems. However, a majority reported being ill equipped to treat substance use disorders themselves; they usually referred such patients to specialty substance use disorder treatment programs. Offering fewer specialty substance use disorder services within the VA may be problematic: providers can refer patients to specialty programs only if such programs exist. Caring for veterans with substance use disorders may require increasing the capacity of and establishing new specialty programs or expanding the ability of psychiatric programs and primary care practitioners to provide such care.