Predictors of substance abuse treatment need and receipt among homeless women

Perceived Unmet Need for Care and Barriers to Care Among Individuals with Mental Health Issues: A Meta-analysis

Unmet needs refer to the gap between the health services individuals require and what they receive. Individuals with mental health issues often face barriers preventing them from accessing the care they need. A meta-analysis was conducted to estimate the pooled prevalence of unmet needs for care and barriers to care among individuals with mental health issues. The databases PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant studies published from December 1, 1985 to August 1, 2024. Following the screening process, 204 included studies remained for meta-analysis. Individuals with mental health issues reported significant pooled prevalence rate of unmet care needs over the past year, with the most common being related to work/occupation (43%), dental care (41%), counseling (40%), social intervention (37%), mental health (34%), physical health needs (33%), skills training (32%), social network (32%), psychological distress (31%), information (27%), intimate relationships (27%), benefits (26%), harm reduction (25%), psychotic symptoms (24%), housing (24%), money and food (21%), education (20%), sexual expression (19%), home care (16%), safety (15%), self-care (15%), telephone support (9%), and child care (8%). The pooled prevalence rates of barriers to accessing care were motivational (38%), structural (37%), financial (31%), and stigmatization (25%). The findings indicated that patients with substance use disorders experienced a significantly higher prevalence of unmet care needs and barriers to accessing care compared to those with mental health disorders and homeless individuals. The results showed that unmet care needs were highest among those in established adulthood, while harm reduction was more common among adolescents and emerging adults. Physical health and food needs were most prevalent among midlife adults. Barriers to care were most common among adolescents and emerging adults, except for structural barriers, which were most frequent among midlife adults. To address the unmet employment needs of Individuals with mental health issues, comprehensive training in essential skills is recommended. Enhancing dentists' mental health understanding and fostering collaboration among healthcare providers is crucial. Government-funded, low-barrier service models for substance use disorder patients is suggested to enhance accessibility and effectiveness, while improving health service affordability and acceptability is essential.

Barriers to Accessing Addiction Treatment for Women at Risk of Homelessness

Women remain under-represented in addiction treatment, comprising less than a third of clients in treatment services. Shame, stigma, and fear of legal and social repercussions (e.g., child protection involvement) are major barriers impacting on treatment-seeking for women. This is compounded for women at risk of homelessness, with practical and logistical reasons for not engaging in treatment. We conducted a qualitative study with both clinicians and service-providers, and women with lived experience of addiction and at risk of homelessness, to identify barriers to access and help-seeking within this vulnerable population. Adult women with lived experience of homelessness and addiction were invited to participate in an online focus group. Interviews were transcribed and analyzed using framework analysis. Analysis resulted in the identification of barriers to access in three areas. These were system-related, socio-cultural, and emotional barriers. We also present findings from the focus group recorded in real-time, using the novel method of digital illustration. This study highlights key factors impacting on help-seeking and access to treatment for addiction faced by women at risk of homelessness. The findings of this study highlight important areas of consideration for clinicians and service-providers working with women who experience addiction, as well as informing future research directions for this priority population. Findings are discussed in the context of exigent literature.

At the Intersection of Homeless Encampments and Heroin Addiction: Service Use Barriers, Facilitators, and Recommendations from the City of Philadelphia's Encampment Resolution Pilot

We provide an overview of the pilot and evaluation measures used for an independent evaluation of the Encampment Resolution Pilot (ERP) wherein the City of Philadelphia closed two homeless encampments in May 2018 and sought to assist those displaced by the closures with housing and treatment services. The evaluation used the Rapid Assessment, Response, and Evaluation method to collect qualitative findings on service use barriers and facilitators from open-ended interviews with people staying in the encampments (N = 27) and service providers (N = 10). We assessed how the ERP allowed providers to "push the system" by removing access barriers, and providing amenable, effective, and accessible housing and drug treatment services that led to more widely adopted best practices. However, there was a clear need for additional supportive services and aftercare for those exiting treatment. Providers also cited a need for more integrated medical and mental health services.

The Perceived Stigma of Addiction and Treatment Utilization among Cannabis Addicts in Thailand

Context:

A major social problem among clients with substance use disorders is stigmatization related to health conditions, which contributes to poor mental and physical health circumstances and becomes hazardous to substance abuse treatment. Meanwhile, decreased stigmatization among cannabis users might occur because some people use cannabis without experiencing harm or believe it to be a harmless substance and might not be receiving treatment. Several studies have investigated stigma toward substance use disorder and treatment. However, less is known about how stigmatization influences treatment.

Aims:

To investigate the association between the perceived stigma of addiction and treatment utilization among cannabis addicts.

Materials and Methods:

A cross-sectional design was conducted with consecutive sampling techniques among 977 cannabis users recruited from all 7 compulsory drug detention centers in Thailand. The data were collected by standardized interviewers with a structured interviewing questionnaire. Binary logistic regression was applied to determine the effect of perceived stigma of treatment utilization.

Results:

Most clients were male (84.5%), had a family history of drug problems (54.5%), and had a history of mental health problems (5.1%). Most of them reported moderate-to-high levels of perceived stigma (87.2%) and received treatment (28.9%). Greater perceived stigma was associated with decreased treatment for cannabis abuse.

Conclusions:

The perceived stigma of addiction is a barrier to cannabis abuse treatment utilization. Thus, a better understanding of stigma could reduce its negative impact on seeking and engaging in treatment.

Substance use, stressful life events and mental health: A longitudinal study among homeless women in Madrid (Spain)

The objectives of this study were: (1) to assess the prevalence of substance use among homeless women; (2) to examine the correlates for drug abuse; (3) to analyze paths between early stressful life events, drug abuse and mental health. The methodology was a longitudinal study of women homeless in Madrid (Spain), who were followed for a 24 months period. There were 138 participants interviewed at baseline and 73 participants interviewed at follow-up. We ran bivariate and multivariate analysis to examine the correlates for drug abuse. We also performed path analysis to test the interconnections between stressful life events, drug abuse and mental health. Results at baseline showed that 83.3% of participants had consumed at least one substance in the previous month. Tobacco was the most common substance consumed (70.1%), followed by sedatives (48.6%), alcohol (36.2%), methadone (13.7%), cocaine (7.2%), cannabis (6.5%) and heroin (5.1%). In addition, women who met criteria for drug abuse (19.6% of the sample) were more likely to be younger, have suffered adverse experiences during childhood, have engaged in prostitution, and have ever attempted suicide, in comparison with women who did not meet criteria for drug abuse. Path analysis supported that early stressful life events increased the vulnerability for subsequent negative outcomes among homeless women. These findings have significant implications for understanding how to implement programs for homeless women in Spain.

Homeless women's service use, barriers, and motivation for participating in substance use treatment

BACKGROUND

Homeless women are at high risk for substance use disorder (SUD), and are a growing proportion of the homeless population. However, homeless women experience barriers to engaging in substance use services.

OBJECTIVES

Among homeless women with SUD, to explore service use, motivation to change, service barriers, and willingness to have substance use and mental health problems addressed in primary health care.

METHODS

Women with SUD were sampled from 11 Health Care for the Homeless (HCH) primary care clinics in 9 states, yielding 241 with either an alcohol or drug use disorder who then completed questions about SUD services.

RESULTS

Over 60% of women with dual alcohol and drug use disorders used some type of SUD service in the past year, while 52% with a drug only disorder, and 44% with an alcohol only disorder used services. The most mentioned barrier to service use was depression, but cost, wait time, where to find treatment, and facilities located too far away, were also frequently noted. A large proportion across all groups indicated high motivation for treatment and willingness to discuss their SUD in a primary care setting.

CONCLUSION

There are continued barriers to SUD service use for homeless women despite high motivation for treatment, and willingness to be asked about SUD and mental health problems in primary care. HCH primary care sites should more systematically ask about SUD and mental health issues and address women's expressed need for support groups and alternative therapies to more holistically address their SUD needs.

Network Approaches to Substance Use and HIV/Hepatitis C Risk among Homeless Youth and Adult Women in the United States: A Review

During the United States economic recession of 2008-2011, the number of homeless and unstably housed people in the United States increased considerably. Homeless adult women and unaccompanied homeless youth make up the most marginal segments of this population. Because homeless individuals are a hard to reach population, research into these marginal groups has traditionally been a challenge for researchers interested in substance abuse and mental health. Network analysis techniques and research strategies offer means for dealing with traditional challenges such as missing sampling frames, variation in definitions of homelessness and study inclusion criteria, and enumeration/population estimation procedures. This review focuses on the need for, and recent steps toward, solutions to these problems that involve network science strategies for data collection and analysis. Research from a range of fields is reviewed and organized according to a new stress process framework aimed at understanding how homeless status interacts with issues related to substance abuse and mental health. Three types of network innovation are discussed: network scale-up methods, a network ecology approach to social resources, and the integration of network variables into the proposed stress process model of homeless substance abuse and mental health. By employing network methods and integrating these methods into existing models, research on homeless and unstably housed women and unaccompanied young people can address existing research challenges and promote more effective intervention and care programs.

The syndemic of HIV, HIV-related risk and multiple co-morbidities among women who use drugs in Malaysia: Important targets for intervention

BACKGROUND

Substance use and HIV are syndemic public health problems in Malaysia. Harm reduction efforts to reduce HIV transmission have primarily focused on men with substance use disorders.

OBJECTIVES

To explore HIV risk behaviors, substance use, and social factors associated with poor health outcomes among women who use drugs in Malaysia.

METHODS

A cross-sectional survey of 103 drug-using women in Kuala Lumpur, Malaysia were recruited to assess their medical, psychiatric and social comorbidity as well as their engagement in nationally recommended HIV testing and monitoring activities.

RESULTS

One-third reported having ever injected drugs, with most (68.2%) having recently shared injection paraphernalia. Sex work (44.7%) and infrequent condom use (42.4%) were common as was underlying psychiatric illness and physical and sexual violence during childhood and adulthood. Most women (62.1%) had unstable living situations and suffered from an unmet need for social support and health services. HIV prevalence was high (20%) with only two thirds of women eligible for antiretroviral therapy having received it. Suboptimal HIV testing and/or monitoring was positively associated with interpersonal violence (AOR 2.73; 95% CI 1.04-7.14) and negatively associated with drug injection (AOR 0.28; 95% CI 0.10-0.77).

CONCLUSIONS/IMPORTANCE

Women who use drugs in Malaysia demonstrate considerable medical, psychiatric and social co-morbidity, which negatively contributes to optimal and crucial engagement in HIV treatment-as-prevention strategies. Mental health and social support may be key targets for future public health interventions aimed at drug-using women in Malaysia.

Co-Morbidities Among Persons With Substance Abuse Problems

This article uses the behavioral model for vulnerable populations to evaluate the use of substance abuse treatment services among a sample of 926 substance abusers with one or more vulnerable health designations. A two-stage hierarchical logistic regression was completed to determine the influence of vulnerable and traditional need factors on the probability of receiving substance abuse treatment. Among traditional covariates, increased odds of receiving substance abuse treatment are associated with being either non-Hispanic White, Hispanic, having an income > US$5,000, and having a regular source of care. Among vulnerable covariates, injection drug use (odds ratio [OR] = 2.19, confidence interval [CI] = [1.46, 3.27]) and the receipt of public benefits (OR = 1.98, CI = [135, 2.92]) remain independent risk factors for the receipt of substance abuse treatment. Many who experience substance abuse disorders can also experience a multitude of other vulnerable health classifications, suggesting the need for a comprehensive, multidisciplinary approach to the treatment of substance use disorders.

Patterns of substance use and correlates of lifetime and active injection drug use among women in Malaysia

BACKGROUND

While drug use is associated with HIV risk in Southeast Asia, little is known about substance use behaviors among women, including drug injection.

OBJECTIVES

To describe patterns of substance use among women using alcohol and drugs in Malaysia and identify correlates of lifetime and active drug injection, a risk factor for HIV transmission.

METHODS

A survey of 103 women who used drugs in the last 12 months assessed drug use history and frequency, including drug injection and drug use during pregnancy, self-reported HIV-status, childhood and adulthood physical and sexual abuse, and access to and utilization of harm reduction services, including needle-syringe exchange programs (NSEP) and opioid agonist maintenance therapy (OAT). Principal component analyses (PCA) were conducted to assess drug use grouping.

RESULTS

Amphetamine-type substances (ATS; 82.5%), alcohol (75.7%) and heroin (71.8%) were the most commonly used drugs across the lifetime. Drug injection was reported by 32.0% (n = 33) of participants with 21.4% (n = 22) having injected in the last 30 days. PCA identified two groups of drug users: opioids/benzodiazepines and club drugs. Lifetime drug injection was significantly associated with lower education, homelessness, prior criminal justice involvement, opioid use, polysubstance use, childhood physical and sexual abuse, and being HIV-infected, but not with prior OAT.

CONCLUSION

Women who use drugs in Malaysia report high levels of polysubstance use and injection-related risk behaviors, including sharing of injection equipment and being injected by others. Low OAT utilization suggests the need for improved access to OAT services and other harm reduction measures that prioritize women.

Personal Network Structure and Substance Use in Women by 12 Months Post Treatment Intake

INTRODUCTION

Women with substance use disorders enter treatment with limited personal network resources and reduced recovery support. This study examined the impact of personal networks on substance use by 12 months post treatment intake.

METHODS

Data were collected from 284 women who received substance abuse treatment. At 6 month follow up, composition, support availability and structure of personal networks were examined. Substance use was measured by women's report of any use of alcohol or drugs. Hierarchical multivariate logistic regression was conducted to examine the contribution of personal network characteristics on substance use by 12 months post treatment intake.

RESULTS

Higher numbers of substance using alters (network members) and more densely connected networks at 6 month follow-up were associated with an increased likelihood of substance use by 12 months post treatment intake. A greater number of isolates in women's networks was associated with decreased odds of substance use. Women who did not use substances by 12 months post treatment intake had more non-users among their isolates at 6 months compared to those who used substances. No association was found between support availability and likelihood of substance use.

CONCLUSIONS

Both network composition and structure could be relevant foci for network interventions e.g. helping women change network composition by reducing substance users as well as increasing network connections. Isolates who are not substance users may be a particular strength to help women cultivate within their network to promote sustained sobriety post treatment.

Personal support networks, social capital, and risk of relapse among individuals treated for substance use issues

BACKGROUND

The success of treatment for substance use issues varies with personal and social factors, including the composition and structure of the individual's personal support network. This paper describes the personal support networks and social capital of a sample of Italian adults after long-term residential therapeutic treatment for substance use issues, and analyses network correlates of post-treatment substance use (relapse).

METHODS

Using a social network analysis approach, data were obtained from structured interviews (90-120 min long) with 80 former clients of a large non-governmental therapeutic treatment agency in Italy providing voluntary residential treatments and rehabilitation services for substance use issues. Participants had concluded the program at least six months prior. Data were collected on socio-demographic variables, addiction history, current drug use status (drug-free or relapsed), and the composition and structure of personal support networks. Factors related to risk of relapse were assessed using bivariate and multivariate logistic regression models.

RESULTS

A main goal of this study was to identify differences between the support network profiles of drug free and relapsed participants. Drug free participants had larger, less dense, more heterogeneous and reciprocal support networks, and more brokerage social capital than relapsed participants. Additionally, a lower risk of relapse was associated with higher socio-economic status, being married/cohabiting, and having network members with higher socio-economic status, who have greater occupational heterogeneity, and reciprocate support.

CONCLUSIONS

Post-treatment relapse was found to be negatively associated with the socioeconomic status and occupational heterogeneity of ego's support network, reciprocity in the ties between ego and network members, and a support network in which the members are relatively loosely connected with one another (i.e., ego possesses "brokerage social capital"). These findings suggest the incorporation into therapeutic programming of interventions that address those aspects of clients' personal support networks.

Personal networks of women in residential and outpatient substance abuse treatment

This study compared compositional, social support, and structural characteristics of personal networks among women in residential (RT) and intensive outpatient (IOP) substance abuse treatment. The study sample included 377 women from inner-city substance use disorder treatment facilities. Respondents were asked about 25 personal network members known within the past 6 months, characteristics of each (relationship, substance use, types of support), and relationships between each network member. Differences between RT women and IOP women in personal network characteristics were identified using Chi-square and t-tests. Compared to IOP women, RT women had more substance users in their networks, more network members with whom they had used substances and fewer network members who provided social support. These findings suggest that women in residential treatment have specific network characteristics, not experienced by women in IOP, which may make them more vulnerable to relapse; they may therefore require interventions that target these specific network characteristics in order to reduce their vulnerability to relapse.

Predisposing, enabling and need correlates of mental health treatment utilization among homeless men

There is significant unmet need for mental health treatment among homeless men, but little is known about the correlates of treatment utilization in this population. Within the framework of the Behavioral Model for Vulnerable Populations, this study examines predisposing, enabling and need factors that may be associated with mental health care utilization. Participants were a representative sample of 305 heterosexually active homeless men utilizing meal programs in the Skid Row region of LA. Logistic regression examined the association between predisposing, enabling and need factors and past 30 day mental health service utilization on Skid Row. Results indicated that while need, operationalized as positive screens for posttraumatic stress disorder or depression, was associated with recent mental health care utilization, predisposing and enabling factors were also related to utilization. African-American homeless men, and those men who also reported substance abuse treatment and drop-in center use, had increased odds of reporting mental health care utilization.

Mothers on methadone: care in the NICU

When women addicted to opioids seek prenatal care, the treatment of choice is methadone. Methadone mediates the addiction by reducing fluctuations in maternal serum opioid levels and protecting the fetus from repeated withdrawal episodes. Methadone maintenance is associated with increased maternal weight gain, decreased illegal drug use, and improved compliance with prenatal care. Although the risks are less when compared with street drugs, the risk to the fetus is physical dependence. Despite the magnitude of this national problem, there is a dearth of literature to guide NICU nurses on how to best support mothers of infants with neonatal abstinence syndrome (NAS) in the care of their infants. The purposes of this article are to review what is known about women in methadone treatment who have a history of opioid addiction and apply that evidence to guide neonatal nurses to support mothers of infants with NAS in the NICU.

Gender differences in substance use treatment utilization in the year prior to deployment in Army service members

Although military men have heavier drinking patterns, military women experience equal or higher rates of dependence symptoms and similar rates of alcohol-related problems as men at lower levels of consumption. Thus, gender may be important for understanding substance use treatment (SUT) utilization before deployment. Military health system data were analyzed to examine gender differences in both substance use diagnosis (SUDX) and SUT in 152,447 Army service members returning from deployments in FY2010. Propensity score analysis of probability of SUDX indicated that women had lower odds (AOR: 0.91, 95% CI: 0.86-0.96) of military lifetime SUDX. After adjusting for lifetime SUDX using propensity score analysis, multivariate regression found women had substantially lower odds (AOR: 0.61; 95% CI: 0.54-0.70) of using SUT the year prior to deployment. Findings suggest gender disparities in military-provided SUT and a need to consider whether military substance use assessment protocols are sensitive to gender differences.

Efficacy of ecologically-based treatment with substance-abusing homeless mothers: substance use and housing outcomes

This randomized pilot study tested the efficacy of an integrative treatment targeting homeless substance abusing mothers with young children in their care. Sixty mothers with 2-6 year old children were recruited from a local family shelter. The mothers were randomly assigned to Ecologically-Based Treatment (n=30) or treatment as usual (n=30). The intervention group received 3 months of rental and utility assistance up to $600 per month, case management services, and substance abuse counseling (referred to as supportive services). The treatment as usual group received housing and services through the family shelter and community housing programs. All participants completed follow-up assessments at 3, 6, and 9 months post-baseline. Mothers receiving Ecologically-Based Treatment showed a quicker decline in alcohol frequency and a quicker increase in housing stability. Furthermore, with supportive services, two-thirds of women were successful in maintaining their apartments 6 months after rental assistance ended.

Changes in personal networks of women in residential and outpatient substance abuse treatment

Changes in personal network composition, support and structure over 12 months were examined in 377 women from residential (n=119) and intensive outpatient substance abuse treatment (n=258) through face-to-face interviews utilizing computer based data collection. Personal networks of women who entered residential treatment had more substance users, more people with whom they had used alcohol and/or drugs, and fewer people from treatment programs or self- help groups than personal networks of women who entered intensive outpatient treatment. By 12 months post treatment intake, network composition improved for women in residential treatment; however, concrete support was still lower and substance users are still more prevalent in their networks. Network composition of women in outpatient treatment remained largely the same over time. Both groups increased cohesiveness within the network over 12 months. Targeting interventions that support positive changes in personal networks may heighten positive long term outcomes for women entering treatment.

Bias and variance trade-offs when combining propensity score weighting and regression: with an application to HIV status and homeless men

The quality of propensity scores is traditionally measured by assessing how well they make the distributions of covariates in the treatment and control groups match, which we refer to as "good balance". Good balance guarantees less biased estimates of the treatment effect. However, the cost of achieving good balance is that the variance of the estimates increases due to a reduction in effective sample size, either through the introduction of propensity score weights or dropping cases when propensity score matching. In this paper, we investigate whether it is best to optimize the balance or to settle for a less than optimal balance and use double robust estimation to adjust for remaining differences. We compare treatment effect estimates from regression, propensity score weighting, and double robust estimation with varying levels of effort expended to achieve balance using data from a study about the differences in outcomes by HIV status in heterosexually active homeless men residing in Los Angeles. Because of how costly data collection efforts are for this population, it is important to find an alternative estimation method that does not reduce effective sample size as much as methods that aggressively aim to optimize balance. Results from a simulation study suggest that there are instances in which we can obtain more precise treatment effect estimates without increasing bias too much by using a combination of regression and propensity score weights that achieve a less than optimal balance. There is a bias-variance tradeoff at work in propensity score estimation; every step toward better balance usually means an increase in variance and at some point a marginal decrease in bias may not be worth the associated increase in variance.

Substance Abuse Treatment Stage and Personal Networks of Women in Substance Abuse Treatment

This study examines the relationship among 4 treatment stages (i.e., engagement, persuasion, active treatment, relapse prevention) and the composition, social support, and structural characteristics of personal networks. The study sample includes 242 women diagnosed with substance dependence who were interviewed within their first month of intensive outpatient treatment. Using EgoNet software, the women reported on their 25 alter personal networks and the characteristics of each alter. With one exception, few differences were found in the network compositions at different stages of substance abuse treatment. The exception was the network composition of women in the active treatment stage, which included more network members from treatment programs or 12-Step meetings. Although neither the type nor amount of social support differed across treatment stages, reciprocity differed between women in active treatment and those in the engagement stage. Networks of women in active treatment were less connected, as indicated by a higher number of components, whereas networks of women in the persuasion stage had a higher degree of centralization, as indicated by networks dominated by people with the most ties. Overall, we find social network structural variables to relate to the stage of treatment, whereas network composition, type of social support, and sociodemographic variables (with a few exceptions) do not relate to treatment stage. Results suggest that social context, particularly how social contacts are arranged around clients, should be incorporated into treatment programs, regardless of demographic background.

Barriers to Psychosocial Services among Homeless Women Veterans

Veterans comprise a disproportionate fraction of the nation's homeless population, with women veterans up to four times more likely to be homeless than non-veteran women. This paper provides a grounded description of barriers to psychosocial services among homeless women veterans. Three focus groups were held in Los Angeles, CA, with a total of 29 homeless women veterans. These women described three primary, proximal (current) barriers: lack of information about services, limited access to services, and lack of coordination across services. Compared to non-veteran homeless women, women veterans potentially face additional challenges of trauma exposure during military service, post-military readjustment issues, and few services specific to women veterans. Understanding their service needs and experiences is critical to the development of relevant and appropriate services that move homeless women veterans away from vulnerability, into safety.

Correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual methamphetamine users

While many studies have examined correlates of trading sex for money, few have examined factors associated with exclusive trading of sex for drugs. We identified sociodemographic, behavioral, and psychological correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual men and women who were enrolled in a sexual risk reduction intervention in San Diego, California. Of 342 participants, 26% overall (21% of males and 31% of females) reported trading sex for methamphetamine in the past two months. Multiple logistic regression analysis revealed that recently trading sex for methamphetamine was independently associated with being female, homeless, binging on methamphetamine, sexual victimization in the past two months, engaging in anal sex 24 or more times in the past two months, and higher sexual compulsivity scores. Effective interventions for this high-risk population should consider gender-focused counseling for sexual abuse, motivational enhancement therapy, social-cognitive skills training, as well as enhanced access and utilization of social services, including drug treatment.