Utilization Of Substance Abuse Services Research Articles

Clinical psychiatric pharmacist involvement in an outpatient buprenorphine program

Background: Approximately nineteen million individuals in the United States are diagnosed with a substance use disorder (SUD), including many veterans enrolled in the Veterans Health Administration (VHA). The prevalence of SUD within the veteran population has been steadily increasing, resulting in increased utilization of substance abuse services, such as buprenorphine programs for opioid dependence. As this population grows, there is an increased need for multidisciplinary services. Clinical psychiatric pharmacists do not have prescriptive authority for buprenorphine, but can play a vital role in outpatient buprenorphine programs. Description of Innovative Service: The clinical psychiatric pharmacist is involved in many aspects of the outpatient buprenorphine program. There are over 100 patients enrolled in the buprenorphine program at the White River Junction Veterans Affairs Medical Center (WRJVAMC). The clinical pharmacist devotes approximately ten hours per week to the program, which includes dispensing the medication, monitoring lab values, patient counseling and random medication counts. A spreadsheet is maintained and updated weekly to monitor doses, refill dates and urine toxicology results. The clinical pharmacist is also involved in the dispensing process in the outpatient pharmacy; this allows for open communication between the clinical pharmacist and patient. Impact on Patient Care: The clinical psychiatric pharmacist has been involved in the outpatient buprenorphine program at the WRJVAMC for approximately two years. Prior to this, the program included less than 100 patients, pharmacy wait times were over sixty minutes and early refills were frequent. Since clinical pharmacy involvement, the pharmacy wait time is approximately 30 minutes or less and early refills are infrequent. Patient satisfaction has also significantly improved. The clinical pharmacist has helped open the lines of communication between the patient, the pharmacy and the prescriber. Conclusion: Substance use disorder programs, such as buprenorphine programs, can benefit from clinical pharmacy involvement. Even with limited prescriptive authority, clinical psychiatric pharmacists can play an important and active role in outpatient buprenorphine programs.

Factors Associated with the Health Service Utilization of Unsheltered, Chronically Homeless Adults

Individuals who are chronically homeless have significantly higher rates of morbidity at significantly younger ages because they experience homelessness, physical and mental health impairments, and substance use disorders. The health status and health service utilization of 260 unsheltered, chronically homeless individuals in a large southwestern, metropolitan community are reported. The behavioral model for vulnerable populations was used to conceptualize the factors associated with hospital, mental health, and substance abuse service utilization among the sample. Health insurance coverage was positively associated with the use of all health services. Other factors were also observed to exert differential relationships to health service utilization.

Predictors of Accessing Substance Abuse Services Among Individuals With Mental Disorders Released From Correctional Custody

Objective: In the context of an increasing correctional population and corresponding rates of mental illness and substance abuse among this population, this study focuses on describing the predictors of substance abuse service utilization for ex-inmates with dual disorders. Our aim is to assess the likelihood and characteristics of ex-inmates with mental disorders who access substance abuse treatment services within 2 years of correctional release. Methods: Using merged administrative data on all ex-inmates with open mental health cases released from the Massachusetts Department of Corrections and two county houses of corrections from 2007 to 2009 (N = 2,280) and substance abuse treatment outcome data through 2011, we analyze the influence of demographics, behavioral and mental disorders, and criminal justice variables on entry into substance abuse treatment within 24 months post-release. We also describe primary drug use and services utilized for all the ex-inmates who accessed substance abuse services (n = 1,383). Regression techniques were used to analyze the probability of utilizing substance abuse treatment services by various demographic, behavioral, and criminal involvement characteristics. Results: The prevalence of a history of substance use disorders is high in this population (69%, n = 1,285). Subsequently, at 24 months post release, 61% (n = 1,383) of ex-inmates with open mental health cases utilized substance abuse treatment services. This group was disproportionately female and White, with a preincarceration history of substance abuse and an increased number of previous incarcerations, and was more likely released under correctional supervision. Conclusions: Substance abuse is a chronic relapsing disorder and dual diagnosis is common among individuals with mental disorders involved with the criminal justice system. Their service needs and contacts across substance abuse, mental health, and criminal justice systems highlight individuals caught up in the institutional circuit. Study results point to the need for expanded and targeted dual diagnosis treatment approaches and relapse prevention for ex-inmates with mental disorders post correctional release.

Effect of Insurance Parity on Substance Abuse Treatment

This study examined the impact of insurance parity on the use, cost, and quality of substance abuse treatment. The authors compared substance abuse treatment spending and utilization from 1999 to 2002 for continuously enrolled beneficiaries covered by Federal Employees Health Benefit (FEHB) plans, which require parity coverage of mental health and substance use disorders, with spending and utilization among beneficiaries in a matched set of health plans without parity coverage. Logistic regression models estimated the probability of any substance abuse service use. Conditional on use, linear models estimated total and out-of-pocket spending. Logistic regression models for three quality indicators for substance abuse treatment were also estimated: identification of adult enrollees with a new substance abuse diagnosis, treatment initiation, and treatment engagement. Difference-in-difference estimates were computed as (postparity - preparity) differences in outcomes in plans without parity subtracted from those in FEHB plans. There were no significant differences between FEHB and non-FEHB plans in rates of change in average utilization of substance abuse services. Conditional on service utilization, the rate of substance abuse treatment out-of-pocket spending declined significantly in the FEHB plans compared with the non-FEHB plans (mean difference=-$101.09, 95% confidence interval [CI]=-$198.06 to -$4.12), whereas changes in total plan spending per user did not differ significantly. With parity, more patients had new diagnoses of a substance use disorder (difference-in-difference risk=.10%, CI=.02% to .19%). No statistically significant differences were found for rates of initiation and engagement in substance abuse treatment. Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care.

Effect of Insurance Parity on Substance Abuse Treatment

Objective: This study examined the impact of insurance parity on the use, cost, and quality of substance abuse treatment. Methods: The authors compared substance abuse treatment spending and utilization from 1999 to 2002 for continuously enrolled beneficiaries covered by Federal Employees Health Benefit (FEHB) plans, which require parity coverage of mental health and substance use disorders, with spending and utilization among beneficiaries in a matched set of health plans without parity coverage. Logistic regression models estimated the probability of any substance abuse service use. Conditional on use, linear models estimated total and out-of-pocket spending. Logistic regression models for three quality indicators for substance abuse treatment were also estimated: identification of adult enrollees with a new substance abuse diagnosis, treatment initiation, and treatment engagement. Difference-in-difference estimates were computed as (postparity - preparity) differences in outcomes in plans without parity subtracted from those in FEHB plans. Results: There were no significant differences between FEHB and non-FEHB plans in rates of change in average utilization of substance abuse services. Conditional on service utilization, the rate of substance abuse treatment out-of-pocket spending declined significantly in the FEHB plans compared with the non-FEHB plans (mean difference=−$101.09, 95% confidence interval [CI]=−$198.06 to −$4.12), whereas changes in total plan spending per user did not differ significantly. With parity, more patients had new diagnoses of a substance use disorder (difference-in-difference risk=.10%, CI=.02% to .19%). No statistically significant differences were found for rates of initiation and engagement in substance abuse treatment. Conclusions: Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care. (Psychiatric Services 62:129–134, 2011)

Service Use and Barriers to Care among Heroin Users: Results from a National Survey

Background: Heroin use is associated with many serious consequences.While effective treatments exist, barriers to services persist. Understanding service use and barriers to treatment can structure treatment practice and target interventions for those who are most at risk. Objectives: To describe patterns and correlates of substance abuse service utilization and treatment barriers among a nationally representative sample of heroin users. Methods: Data for this study were derived from the National Epidemiologic Survey on Alcohol and Related Conditions. This study focused on lifetime heroin users (N = 150). Results: Fifty-nine percent of heroin users reported receiving at least one treatment service. The most common services used were 12-step programs, detoxification, and rehabilitation. Approximately 44% reported at least one barrier to treatment. The most common were lack of motivation and beliefs that it could be managed alone. In a multivariate logistic regression, having a heroin use disorder was associated with a greater likelihood of receiving services (OR = 6.09) and experiencing a barrier (OR = 11.11) compared to those without a disorder. Conclusions and Scientific Significance: High rates of service use and barriers were observed for all levels of heroin involvement. These findings underscore the importance of improving access to services for this group, even when full criteria for a drug disorder is not met. Integration of motivational approaches is also needed within the most common services used. To our knowledge, this is the first study to describe patterns and correlates of service use using a nationally representative community sample of heroin users.

Brief Motivational Interviewing for DWI Recidivists Who Abuse Alcohol and Are Not Participating in DWI Intervention: A Randomized Controlled Trial

Driving while impaired (DWI) recidivists with unresolved alcohol use problems pose an ongoing risk for traffic safety. Following conviction, many do not participate in mandated alcohol evaluation and intervention programs, or continue to drink problematically after being relicensed. This study investigated if, in DWI recidivists with alcohol problems and not currently involved in DWI intervention, Brief Motivational Interviewing (BMI) produced greater reductions in risky drinking at 6- and 12-month follow-up compared to an information-advice control condition. Additional analyses explored whether BMI was associated with greater readiness to change, subsequent substance abuse treatment service utilization, and satisfaction compared to the control condition. Male and female recidivists with drinking problems and not currently engaged in DWI intervention were recruited, evaluated, and then randomly assigned to receive 1 of 2 manualized interventions: 30-minute BMI session or information-advice. Participants, interviewers, researchers, and statisticians were blind to assignment. Outcomes were changed in: percent of risky drinking days (i.e., > or =3 standard drinks/d for males; > or =2 for females) in the previous 6 months derived from the Timeline Followback, biomarkers of alcohol abuse (GGT, AST, ALT, MCV) by blood assay, and alcohol abuse-related behaviors using the MMPI-Mac scale. Data from the Readiness to Change Questionnaire, a substance abuse service utilization questionnaire, and the Client Satisfaction Scale were also collected. Analyses revealed significant declines in risky drinking with both interventions. BMI (n = 92) resulted in a 25% reduction in risky drinking days at 12-month follow-up, which compared to the control intervention (n = 92) represented a significant decline from 6-month levels. Exposure to BMI also produced significantly greater improvement at 6-month follow-up in a biomarker of alcohol abuse and a behavioral measure related to recidivism risk. Exploration of readiness to change, substance abuse service utilization, and satisfaction with intervention indicated a perception of BMI being more useful in coping with problems. Brief MI approaches warrant further implementation and effectiveness research as an opportunistic DWI intervention strategy to reduce risks associated with alcohol use outside of clinical and DWI relicensing settings.

Ability of the Behavioral Model to Predict Utilization of Five Services by Individuals Suffering from Severe Mental Illness and Homelessness

This study examined the ability of the behavioral model to predict utilization of five specific services in a sample of individuals who suffered from severe mental illness and who were homeless at baseline. Nearly 4000 individuals from 18 sites provided data at baseline and 12 months later for this study. Hierarchical logistic regression was used to analyze the data. The behavioral model did not explain much of the variance of utilization of medical services, housing services, and public support. The behavioral model did explain a moderate amount of the variance of utilization of psychiatric services and substance abuse services. Enabling variables explained more of the variance of psychiatric services than either predisposing or need variables. In contrast, predisposing and need variables explained more of the variance of utilization of substance abuse services than enabling variables. Social support from professionals and self-perceived need for service were the most consistent predictors of all of the service utilization variables.

Racial and Gender Differences in Utilization of Medicaid Substance Abuse Services Among Adolescents

This study examined race and gender disparities in utilization of substance abuse treatment among adolescents enrolled in Medicaid in Tennessee. By using Medicaid enrollment, encounter, and claims data, utilization of substance abuse services for the population of adolescents enrolled in TennCare was examined in two ways. The first utilization measure considered annual utilization rates and probability of use of substance abuse services for the statewide population of enrolled adolescents (approximately 170,000 per year). The second examined the age at which the first substance abuse service was received for the 8,473 youths who had that service paid for by TennCare during state fiscal years 1997 to 2001. Proportionally, among adolescents, more whites than blacks and more males than females used substance abuse services. The disparities were greater than differences in prevalence rates explain. Black females had the greatest disparity in service utilization. Whites and females received their first substance abuse service at a younger age than blacks or males in this Medicaid population. However, the age difference may not be clinically significant. The low utilization rates, in general, and the disparities in service use by race and gender raise questions about the identification of substance use problems at both provider and system levels.

Race/Ethnic Disparity and Correlates of Substance Abuse Service Utilization and Juvenile Justice Involvement Among Adolescents with Substance Use Disorders

ABSTRACT This study examines correlates of level of specialty alcohol/drug services care and juvenile justice system involvement for adolescents with substance use disorders. Participants were 420 adolescents 13-18 years of age randomly sampled from all youths active in at least one of five youth sectors of care in San Diego County, California. Adolescents were assessed using structured diagnostic interviews including the Diagnostic Interview Schedule for Children-IV and the Composite International Diagnostic Interview-Substance Abuse Module. Analyses examined effects of age, sex, race/ethnicity, mental health disorders, functional impairment, and type and number of substance use disorders in relation to specialty and non-specialty services. Non-Caucasian youths were less likely to receive the least restrictive services and more likely to be found in juvenile justice settings. A number of SUDs (substance use disorders) were positively associated with outpatient, residential, and JJ (juvenile justice) services. Marijuana use disorder was positively associated and stimulant use disorder negatively associated with use of outpatient services. Ethnic disparities exist in relation to restrictiveness of specialty care and juvenile justice system involvement. Type of substance use disorder is also differentially associated with specialty care. Standardized assessment and treatment planning should be implemented across youth sectors of care in order to decrease racial/ethnic disparities and allow for appropriate services for youths with substance use disorders.

Injection Drug Use Among Stimulant Users in a National Sample

Objective. This study examined the correlates of injection drug use (IDU) in a community sample of psychostimulant users. Factors related to the cessation of illicit drug use and substance abuse service utilization were also determined among a subsample of stimulant users who reported IDU. Method. The study sample consisted of 3408 lifetime psychostimulant users from the National Household Survey on Drug Abuse. Logistic regression procedures were used to estimate independent associations of correlates of IDU. Results. Approximately one in seven lifetime stimulant users reported IDU in their lifetime. Stimulant users with a lifetime history of IDU were more likely than those who did not inject to be African‐American, not have received a high school diploma, have a history of multiple drug use, and report an onset of stimulant use before age 18. Among recent stimulant users, being aged 26 or older, using stimulants at least weekly, and getting drunk in the past year were associated with increased odds of recent IDU. Only one‐half of all injection drug users reported having ever used substance abuse services. Cessation of illicit drug use among injectors with a history of stimulant use is common (44%). Conclusions. Further studies should clarify the natural history of IDU among stimulant users, including the cessation of drug use without participating in substance abuse treatment services.

Utilization of Mental Health and Substance Abuse Services Among Homeless Adults in Los Angeles

Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.

Impact of substance abuse and child maltreatment training on service utilization in a rural setting

Substance abuse and child maltreatment have been recognized as co-morbid problems encountered in families presenting in the child protective services (CPS) system. Nonetheless, utilization rates of substance abuse treatment services have generally lagged well behind what the research would suggest are prevalence rates for substance abuse disorders in this population, suggesting problems in recognition and referral practices among CPS workers. In response to this, 25 training programs were funded by the National Center on Child Abuse and Neglect. This study reports data from one program. Trainees indicated a high level of satisfaction and demonstrated significant knowledge gains. More importantly, utilization of substance abuse services increased significantly across time in a multi-county region receiving training relative to a comparison region receiving none. The gain was limited, suggesting that while increased knowledge may translate into increased service utilization, additional barriers to accessing needed services must also be addressed.

Barriers to mental health care for Hispanic Americans: a literature review and discussion.

The Hispanic American population, the second largest and fastest growing minority population in the United States, faces barriers to access to both medical health and mental health care. This paper examines both financial and cultural barriers to utilization of mental health care services; it is a broad review of the literature and is not intended to be comprehensively detailed. The research review suggests that the financial barrier is a major determinant of mental health service access for Hispanic American populations. Also, nonfinancial barriers such as acculturation are examined. A two-part plan is suggested to reduce both financial and nonfinancial barriers. Very little literature on utilization of substance abuse services was found; suggestions for further research are thus proposed.