Correlates of specialty substance use treatment among adults with opioid use disorders
Introduction
There has been a dramatic increase in opioid use in the United States in the last two decades. From 1999 to 2010, sales of prescription opioids in the U.S. nearly quadrupled (Centers for Disease Control and Prevention (CDC), 2011), and the prevalence of prescription opioid misuse and abuse increased in parallel (McHugh, Nielsen, & Weiss, 2015). These increases are thought to have contributed to a subsequent increase in heroin use as the prevalence of past-year heroin use nearly doubled between 2005 and 2012 (Substance Abuse and Mental Health Services Administration, 2013). As a result of increases in prescription opioid and heroine abuse, drug overdoses, the majority of which are opioid-related, are now the leading cause of accidental death in the U.S (Levi, Segal, & Martin, 2015).
The increase in opioid abuse in the U.S. has meant an increase in the number of individuals needing treatment (Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2015). From 2003 to 2013, the number of U.S. individuals aged 12 years or older with an opioid use disorder (OUD) increased from 1.6 million to 2.4 million (Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States, 2015). A variety of evidence-based treatments for OUD exist in the U.S., including pharmacologic treatments such as methadone, buprenorphine and naltrexone. Medication-assisted therapy (MAT), now considered to be the frontline treatment for OUD, uses pharmacologic interventions in combination with psychosocial interventions such as motivational interviewing and cognitive behavioral therapy (Schuckit, 2016). Unlike in other countries where MAT is more accessible (European Monitoring Centre for Drugs and Drug Addiction, n.d.; Merrill, 2002), U.S. federal laws and regulations limit where opioid agonist pharmacotherapies can be administered. Methadone can only be dispensed at federally certified opioid treatment programs, and buprenorphine can only be prescribed by physicians who have completed special training (Substance Abuse and Mental Health Services Administration, 2015). Despite increased demand, very few individuals in need of treatment receive MAT or other treatment. Between 2009 and 2013, only 21.5% of individuals aged 12 and older with an OUD received any treatment in the previous year (Saloner & Karthikeyan, 2015).
Although there is substantial unmet need for treatment (Becker et al., 2008; Saloner & Karthikeyan, 2015), our knowledge of factors associated with receiving treatment is limited. Barriers to accessing treatment in the U.S. include insufficient health insurance coverage, insufficient treatment capacity, and the stigma of addiction and treatment (Appel, Ellison, Jansky, & Oldak, 2004; Becker et al., 2008; Jones, Campopiano, Baldwin, & McCance-Katz, 2015). As state and federal governments in the U.S. try to address unmet treatment need for those with OUD, particularly by expanding treatment capacity, it is important to first understand who is likely to receive treatment. Doing so requires understanding the complex patient-level factors that influence treatment. Previous studies using national data have rarely focused on identifying correlates of receiving evidence-based treatments among adults with OUD. Prior studies have examined individuals with any substance use disorder (SUD) (Grella, Karno, Warda, Moore, & Niv, 2009; Harris & Edlund, 2005; Wu, Ringwalt, & Williams, 2003) or have been limited to adolescents or veterans with OUD (Finlay et al., 2016; Oliva, Harris, Trafton, & Gordon, 2012; Shiner, Leonard Westgate, Bernardy, Schnurr, & Watts, 2017; Wu, Blazer, Li, & Woody, 2011). A recent study by Wu et al. (Wu, Zhu, & Swartz, 2016) investigated correlates of receiving treatment among adults and adolescents with OUD but did not include patient-level factors, such as criminal history and employment status, that may be particularly salient for vulnerable populations.
In this study, we aimed to identify correlates of receiving substance use treatment at a specialty treatment facility among adults with OUD in the U.S. Using a large, nationally representative sample, we: 1) examined potential correlates of treatment receipt as guided by the Gelberg-Andersen behavior model of health services utilization; 2) estimated the prevalence of perceived need of treatment; and 3) evaluated reported reasons for not receiving treatment. We focused on adults since adolescents and adults with OUD are distinct populations who differ in the treatment options available to them (American Society of Addiction Medicine, n.d.) and likely face different barriers to treatment. Unlike several previous studies (Feder et al., 2017; Saloner & Karthikeyan, 2015; Wu et al., 2016), we chose to only consider treatment received at facilities that could offer evidence-based treatments for OUD.
Section snippets
Data source
Data for this study come from individual waves of the National Survey on Drug Use and Health (NSDUH), a nationally representative, cross-sectional survey conducted annually in the continental U.S. NSDUH provides national estimates of alcohol and illicit drug use, substance use disorders, and treatment for those disorders. NSDUH samples from civilian, non-institutionalized U.S. residents aged 12 years and older. NSDUH uses multi-stage area probability sampling of dwelling units, including
Results
Of individuals with OUD, 8.3% received specialty treatment in the past 12 months (95% confidence interval (CI): 6.5% to 10.5%). Among those who received specialty treatment, 66.4% received treatment at 2 or more different specialty treatment facilities. Approximately one quarter (25.7%) of all respondents who received specialty treatment received treatment at 4 or more different specialty treatment facilities. As shown in Table 1, rehabilitation facilities were the most common treatment
Discussion
In a large, nationally representative sample of adults with OUD in the U.S., we found that the prevalence of specialty substance use treatment receipt was low, as was the perceived need of treatment. Factors positively associated with past-year receipt of specialty substance use treatment included older age, being unemployed or out of the labor force, having never been married, an arrest in the past 12 months, opioid dependence (vs. abuse), having an AUD, and having another drug use disorder.
Role of funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Contributors
All authors have contributed to and approved the final manuscript. Eric Romo and Kate Lapane designed the initial study and protocol. Eric Romo performed literature searches, conducted the analyses, and wrote the first draft of the manuscript. Christine Ulbricht, Robin Clark, and Kate Lapane provided input throughout the conduct of the study and edited subsequent versions of the manuscript.
Conflict of interest
There are no conflicts of interest.
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County-level sociodemographic differences in availability of two medications for opioid use disorder: United States, 2019
2022, Drug and Alcohol DependenceCitation Excerpt :Even in areas where there may be capacity for both methadone and buprenorphine treatment, there is evidence that it is not equitably accessible. Previous studies suggest that patients receiving buprenorphine may be predominately White, have higher education levels and reside in non-urban areas compared to patients receiving methadone (Blanco et al., 2013; Wu et al., 2016; Romo et al., 2018). Hansen et al. (2013) found significant differences in treatment rates in New York City between methadone and buprenorphine by the ethnicity and income characteristics by ZIP code (Hansen et al., 2013), while Goedel et al. (2020) found that racial/ethnic composition of a community was associated with the types of medications residents would likely be able to access when seeking treatment for OUD (Goedel et al., 2020).
Geographic access to buprenorphine prescribers for patients who use public transit
2020, Journal of Substance Abuse TreatmentCitation Excerpt :First, existing car-based Medicaid access monitoring standards often do not reflect whether persons dependent upon public transit can reach buprenorphine prescribers in a reasonable timeframe. This is particularly troubling because most persons with OUD reside in urban areas (Romo, Ulbricht, Clark, & Lapane, 2018). After incorporating estimates of car availability and public transit travel times, we found that many urban households cannot access a buprenorphine prescriber within 30 min even though one is available within a 30-min car drive.
Impact of health reform on health insurance status among persons who use opioids in eastern Kentucky: A prospective cohort analysis
2019, International Journal of Drug PolicyCitation Excerpt :Furthermore, only about half of rural physicians holding the buprenorphine waiver are accepting new patients (Andrilla, Coulthard, & Patterson, 2018). Such disparities in service availability helps to explain, for example, why individuals living in rural areas are significantly less likely to receive specialty OUD treatment (Romo, Ulbricht, Clark, & Lapane, 2018). Several limitations should be noted.
Prevention and Treatment of Opioid Overdose and Opioid-Use Disorders
2018, Addictive BehaviorsComparing buprenorphine-prescribing physicians across nonmetropolitan and metropolitan areas in the United States
2019, Annals of Family MedicineCitation Excerpt :Access to mental health resources and patient factors that differ between nonmetropolitan and urban areas may affect buprenorphine treatment practices and quality. There is less availability of therapists, psychiatrists, and other clinicians in nonmetropolitan areas to treat mental health disorders, which are often comorbid in patients with OUD.12–14 Patients in nonmetropolitan areas often travel much longer distances to seek treatment, which has been associated with receiving fewer mental health visits and less guideline-concordant mental health treatment.15