Barriers and Facilitators to Treatment Engagement Among Clients in Inpatient Substance Abuse Treatment

Examining facilitative services for entry into substance use disorder treatment: A cluster analysis of treatment facilities

OBJECTIVES

We examined services to facilitate access to entering substance use disorder (SUD) treatment among a national sample of SUD treatment facilities.

METHODS

We analyzed data from the National Survey of Substance Abuse Treatment Services (N-SSATS) 2020. Facilities were included in the sample based on criteria such as SUD treatment provision and being in the U.S. Cluster analysis was conducted using variables including ownership, levels of care, and whether facilities provide services or accept payment options aimed at reducing treatment barriers. National and state-level data on the percentage of facilities in each cluster were presented.

RESULTS

Among N = 15,788 SUD treatment facilities four distinct clusters were identified: Cluster 1 consisted of for-profit and government outpatient facilities with high proportions of services to reduce barriers (22.2%). Cluster 2, comprised of non-profit outpatient facilities, offered the most comprehensive array of services to minimize barriers to treatment among all four clusters (25.2%). Cluster 3 included facilities with diverse ownership and care levels and provided a moderate to high degree of services aimed at reducing entry barriers to treatment (26.0%). Cluster 4 was primarily for-profit outpatient facilities with a low proportion of these services (26.6%).

CONCLUSIONS

This study revealed facility-level groupings with different services to reduce barriers to SUD treatment across various clusters of SUD treatment facilities. While some facilities offered extensive services, others provided fewer. Differences in cluster distributions point to possible facilitators to treatment access for some persons seeking admission to specific treatment facilities. Efforts should be made to ensure that individuals seeking SUD treatment can access these services, and facilities should be adequately equipped to meet their diverse needs.

Smoking Policies of Outpatient and Residential Substance Use Disorder Treatment Facilities in the United States

Tobacco use is associated with morbidity and mortality. Many individuals who present to treatment facilities with substance use disorders (SUDs) other than tobacco use disorder also smoke cigarettes or have a concomitant tobacco use disorder. Despite high rates of smoking among those with an SUD, and numerous demonstrated benefits of comprehensive SUD treatment for tobacco use in addition to co-occurring SUDs, not all facilities address the treatment of comorbid tobacco use disorder. In addition, facilities vary widely in terms of tobacco use policies on campus. This study examined SUD facility smoking policies in a national sample of N = 16,623 SUD treatment providers in the United States in 2021. Most facilities with outpatient treatment (52.1%) and facilities with residential treatment (67.8%) had a smoking policy that permitted smoking in designated outdoor area(s). A multinomial logistic regression model found that among facilities with outpatient treatment (n = 13,778), those located in a state with laws requiring tobacco free grounds at SUD facilities, those with tobacco screening/education/counseling services, and those with nicotine pharmacotherapy were less likely to have an unrestrictive tobacco smoking policy. Among facilities with residential treatment (n = 3449), those with tobacco screening/education/counseling services were less likely to have an unrestrictive tobacco smoking policy. There is variability in smoking policies and tobacco use treatment options in SUD treatment facilities across the United States. Since tobacco use is associated with negative biomedical outcomes, more should be done to ensure that SUD treatment also focuses on reducing the harms of tobacco use.

Barriers and facilitators to accessing adolescents' mental health services in Karachi: users and providers perspectives

INTRODUCTION

Adolescents' Mental Healthcare (MHC) is influenced by numerous factors, and adolescents occasionally seek professional help for mental health (MH) issues. These factors become more complex within low-middle-income countries (LMICs); therefore, this study aims to understand barriers and facilitators to access mental health services among adolescents aged 10 to 19 years old from the perspective of users (parents) and providers (Mental Healthcare Providers - MHPs).

METHOD

Using a qualitative exploratory design, a semi-structured interview guide was developed using Andersen's health service utilization model. In-depth interviews were conducted with MHPs (n = 21) and parents of adolescents (n = 19) in the psychiatry department of public and private hospitals in Karachi, from October-December 2021. Data was thematically analyzed using an inductive approach.

RESULT

The findings revealed a consensus of users and providers in all three categories of the Andersen model and referred the compulsion as the major driving force to MHC access and utilization rather than personal choices. Within pre-disposing, need, and enabling factors; the participants highlighted a unique perspective; users regarded frequent migration, daily wage loss, and women's societal status as barriers while the need for marriage and patient willingness were stated as facilitators. Whereas, MHPs indicated societal tolerance, the burden on the health system, and the absence of Child and Adolescent Mental Health (CAMH) services as major gaps in service delivery.

CONCLUSION

Service utilization is mainly facilitated by the severity of illness rather than healthy choices and beliefs, and accessibility and affordability. It is therefore imperative to prioritize adolescent MH through promotion and prevention approaches and address service delivery gaps to prevent treatment delays via task-shifting and capacity building of the health workforce.

Uncovering Barriers to Engagement in Substance Use Disorder Care for Medicaid Enrollees

OBJECTIVE

The authors aimed to uncover factors that affect engagement in substance use disorder treatment among Medicaid beneficiaries in New York State.

METHODS

The authors conducted 40 semistructured interviews with clients, plan administrators, health care providers, and policy leaders directly involved with substance use care in New York State. Data were analyzed with thematic analysis.

RESULTS

Main themes resulting from analysis of the 40 interviews showed that most stakeholders agreed that a need exists to better integrate psychosocial services into behavioral health care systems; that systemic stigma, stigma from providers, and lack of cultural responsiveness in the substance use care system hinder engagement in and provision of high-quality care; and that rural health care networks with coordinated models benefit clients' engagement in care.

CONCLUSIONS

Stakeholders involved in care for substance use disorder perceived a lack of integration of resources to meet clients' social needs, the presence of stigma, and low levels of cultural and linguistic capacity as key factors contributing to low engagement in and low quality of care for substance use disorder. Future interventions should address social needs within the therapeutic regimen and modify curricula in clinical training to reduce stigma and increase cultural competence.

Outpatient substance abuse treatment completion rates for racial-ethnic minorities during the Great Recession

There has been minimal research linking the effects on racial-ethnic minorities' health outcomes, particularly research focused on racial-ethnic minorities seeking outpatient substance abuse treatment in the United States. The Great Recession from December 2007 to June 2009 in the United States provides the backdrop against the completion of substance abuse treatments among racial-ethnic minorities that may be associated with the impacts on users' social realities. We utilized data from the 2006-2011 Treatment Episode Datasets-Discharge (TEDS-D) dataset which collects data on outpatient substance abuse treatment institutions throughout the United States. The substance abuse treatment completion rates were higher prior to the Great Recession and lower following the Great Recession. Hispanics were more likely than non-Hispanic whites to complete substance abuse treatment, while other minority groups such as Non-Hispanic Blacks, were less likely to do so. Clients in the Northeast and West regions were more likely to successfully complete substance abuse treatment than those in the South. These findings have implications for impacting outpatient substance abuse treatment completion rates following the Great Recession to reduce racial-ethnic disparities which were impacted by region. Even amid an economic recession, treatment for substance abuse should continue to be a top concern.

"Can we get a Black rehabilitation center"? Factors impacting the treatment experiences of Black people who use opioids

INTRODUCTION

With opioid overdose rates doubling in the state of Kentucky over the last year, the opioid crisis is having a deadly impact on the state. Among Black individuals in particular, overdose rates have increased by nearly a third. As such, we must examine ways to effectively intervene to reduce deaths among this underrepresented population.

METHOD

The current study utilized a thematic analysis to examine factors influencing treatment perceptions and experiences among a sample of 39 Black adults with a recent history of opioid use.

RESULTS

The primary themes highlighted in the study included "autonomous accessibility," "provider characteristics," and "relational support," which are aligned with Self-Determination Theory.

CONCLUSIONS

We discuss how these themes relate to treatment initiation, engagement, and completion and discuss implications of this research in treatment for Black adults. Specifically, we discuss treatment considerations among Black adults who use prescription opioids such as ensuring autonomy and a collaborative approach to treatment, especially in mandated treatment, with strategies such as motivational interviewing. Further, we discuss the importance of nonjudgmental providers, gauging client preferences for racially, ethnically, and gender matched providers; and we assess support networks among clients and how these networks can be integrated or utilized in treatment planning.

Perspectives on Motivation and Change in an Intervention for Men Who Use Substances and Perpetrate Intimate Partner Abuse: Findings From a Qualitative Evaluation of the Advance Intervention

Despite consistent evidence that substance use is a contributory risk factor for perpetration of intimate partner abuse (IPA), little evidence exists for effective interventions for male IPA perpetrators who use substances. The Advance intervention aimed to meet this need. This 16-week intervention addressed both IPA and substance use, and was for men accessing substance use treatment who had perpetrated IPA toward a female (ex-)partner within the last 12 months. Two key theories underpinned the intervention: goal theory and self-regulation theory. In this article, we aim to illustrate the views of men and substance use treatment staff on men's motivations to change, the ways in which men and staff said that men had changed their behavior, and the aspects of the intervention that they reported were key in the process of change. Using framework analysis, we analyzed data from 12 men who took part in the intervention as well as 31 staff members from substance use treatment services. Our five overarching themes were personal goal setting and motivation; recognition of IPA and the substance using lifestyle; improved self-regulation; considering the impact on others; and learning together in a group. Men and staff valued having a program that integrated IPA and substance use and thought the program was unique and much needed. Moreover, our findings suggest that goal theory, self-regulation, and more broadly, motivational and strengths-based approaches with practice-based activities, may be beneficial for effecting change in the substance using perpetrator population. However, further research is needed to determine the effectiveness of the intervention. Overall, our findings highlight the value of using qualitative outcome measures of perpetrator programs to complement quantitative measures of impact.

How do Past, Present and Future Weigh into Trajectories of Precarity? The Time Perspectives of Young Psychoactive Substance Users Living in Situations of Social Precarity in Montreal

Young psychoactive substance users in social precarity are vulnerable to a range of health and social issues. Time perspective is one aspect to consider in supporting change. This study draws on the views expressed by young adults to portray their subjective experience of time, how this perception evolves and its implications for their substance use and socio-occupational integration trajectories. The sample includes 23 young psychoactive substance users (M = 24.65 years old; 83% male) in social precarity frequenting a community-based harm reduction centre. Thematic analysis of the interviews reveals the past to be synonymous with disappointment and disillusionment, but also a constructive force. Participants expressed their present-day material and human needs as well as their need for recognition and a sense of control over their own destiny. Their limited ability to project into the future was also discussed. Avenues on how support to this population might be adapted are suggested.

Barriers to retention in substance use treatment: Validation of a new, theory-based scale

PURPOSE

Few studies and no theory-based scales have addressed specific barriers to substance use disorder (SUD) treatment retention. The current study, building on the Theory of Planned Behavior (TPB), sought to (a) identify those barriers that are most strongly associated with treatment retention, and most common, and (b) develop and validate a new scale of retention barriers, focusing on TPB attitude and perceived control components.

METHODS

The study administered surveys to 200 participants initiating SUD treatment at a public, outpatient program in Northern California; the analytic sample (N = 156) included only those not strongly coerced into treatment. Surveys included TPB-based measures of treatment barriers; other motivational readiness measures; treatment coercion and social desirability measures; and clinical severity variables and demographics. Discharge status was collected from program records.

RESULTS

Item and scale analyses identified three dimensions of attitudinal barriers (i.e., Low Perceived Treatment Need/Value, Social Concerns, and Concerns about Missing Substances) and two dimensions of perceived control barriers (i.e., Personal Limitations and Basic Logistic Barriers). Results informed creation of a 19-item Barriers to Retention Scale (BRS) with 5 subscales and very good internal reliability (alpha = 0.88). While all subscale scores were correlated with treatment completion, only Concerns about Missing Substances and total BRS scores predicted treatment completion in multivariate analyses.

CONCLUSIONS

The present study identified core dimensions of treatment retention barriers and developed a new scale predictive of treatment completion and potentially useful as a screener and in future research. Results suggest that interventions to improve retention should focus strongly on concerns about the negative impacts of abstaining from alcohol and drugs on craving and quality of life.

Feasibility and acceptability of mindful recovery opioid use care continuum (M-ROCC): A concurrent mixed methods study

As opioid overdose deaths increase, buprenorphine/naloxone (B/N) treatment is expanding, yet almost half of patients are not retained in B/N treatment. Mindfulness-based interventions (MBIs) designed to promote non-judgmental awareness of present moment experience may be complementary to B/N treatment and offer the potential to enhance retention by reducing substance use and addressing comorbid symptoms. In this pilot study, we examined the feasibility and acceptability of the Mindful Recovery OUD Care Continuum (M-ROCC), a trauma-informed, motivationally sensitive, 24-week MBI. Participants (N = 18) were adults with Opioid Use Disorder prescribed B/N. The study team conducted assessments of satisfaction, mindfulness levels, and home practice, as well as qualitative interviews at 4 and 24-weeks. M-ROCC was feasible in a sample with high rates of childhood trauma and comorbid psychiatric diagnoses with 89% of participants retained at 4-weeks and 72% at 24-weeks. Positive qualitative interview responses and a high rate of participants willing to refer a friend (100%) demonstrates program acceptability. Participant mindfulness increased from baseline to 24-weeks (β = 0.24, p = 0.001, d = 0.51), and increases were correlated with informal mindfulness practice frequency (r = 0.7, p < 0.01). Although limited by small sample size, this pilot study highlights the feasibility and acceptability of integrating MBIs into standard primary care Office-Based Opioid Treatment (OBOT) among a population with substantial trauma history.

Implementing a digital mental health intervention for individuals with psychosis - a multi-country qualitative study

BACKGROUND

Implementation of psychosocial interventions in mental health services has the potential to improve the treatment of psychosis spectrum disorders (PSD) in low- and middle-income countries (LMICs) where care is predominantly focused on pharmacotherapy. The first step is to understand the views of key stakeholders. We conducted a multi-language qualitative study to explore the contextual barriers and facilitators to implementation of a cost-effective, digital psychosocial intervention, called DIALOG+, for treating PSD. DIALOG+ builds on existing clinician-patient relationships without requiring development of new services, making it well-fitting for healthcare systems with scarce resources.

METHODS

Thirty-two focus groups were conducted with 174 participants (patients, clinicians, policymakers and carers), who were familiarized with DIALOG+ through a presentation. The Southeast European LMICs included in this research were: Bosnia and Herzegovina, Kosovo, (Kosovo is referred throughout the text by United Nations resolution) North Macedonia, Montenegro and Serbia. Framework analysis was used to analyse the participants' accounts.

RESULTS

Six major themes were identified. Three themes (Intervention characteristics; Carers' involvement; Patient and organisational benefits) were interpreted as perceived implementation facilitators. The theme Attitudes and perceived preparedness of potential adopters comprised of subthemes that were interpreted as both perceived implementation facilitators and barriers. Two other themes (Frequency of intervention delivery; Suggested changes to the intervention) were more broadly related to the intervention's implementation. Participants were exceedingly supportive of the implementation of a digital psychosocial intervention such as DIALOG+. Attractive intervention characteristics, efficient use of scarce resources for its implementation and potential to improve mental health services were seen as the main implementation facilitators. The major implementation barrier identified was psychiatrists' time constrains.

CONCLUSIONS

This study provided important insights regarding implementation of digital psychosocial interventions for people with PSD in low-resource settings by including perspectives from four stakeholder groups in five LMICs in Southeast Europe - a population and region rarely explored in the literature. The perceived limited availability of psychiatrists could be potentially resolved by increased inclusion of other mental health professionals in service delivery for PSD. These findings will be used to inform the implementation strategy of DIALOG+ across the participating countries. The study also offers insights into multi-country qualitative research.

Telehealth during COVID-19: The perspective of alcohol and other drug nurses

AIM

This study aimed to explore the experiences of alcohol and other drug nurses transitioning to telehealth due to the COVID-19 pandemic.

BACKGROUND

COVID-19 has caused immense disruption to healthcare services, and to reduce viral transmission, many services moved to off-site care delivery modalities such as telehealth.

DESIGN

We used a qualitative descriptive design for this study.

METHODS

Secondary analysis of semistructured interviews with alcohol and other drug nurses from Australia and New Zealand (n = 19) was conducted in July and August 2020. Data were analysed using thematic analysis and reported using COREQ guidelines.

RESULTS

Three were identified: '"All our face-to-face contact ceased with clients": Changing service delivery', '"How do I do my job when I can't see you?": An anxious shift in service delivery' and '"A lot of Indigenous people don't like the FaceTiming and all that": Challenges to delivery of services through telehealth'.

CONCLUSION

Participants in our study reported challenges in transitioning to telehealth modalities. The perceived loss of therapeutic communication, difficulties in assessing risks to healthcare consumers such as domestic violence and challenges delivering telehealth care to a marginalized consumer cohort need to be overcome before telehealth is considered successful in alcohol and other drug treatment. However, telehealth was a successful adjunct to existing practices for nurses working with consumers in regional or remote areas or where consumers preferred this method of service delivery.

IMPACT

Nurses in this study described substantial issues with the delivery of alcohol and other drug treatment via telehealth, including a perception that telehealth was a barrier to addressing risks to consumers who use alcohol and other drugs, and difficulties working in a therapeutically beneficial way via telehealth. Telehealth is a means to reduce viral transmission through a reduction in face-to-face contact, and although it may be useful for some service functions, it may be detrimental to the clinical services nurses provide.

Targeting the Barriers in the Substance Use Disorder Continuum of Care With Peer Recovery Support

Substance Use Disorder (SUD) has been recognized as a chronic, relapsing disorder. However, much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery from addiction. The high rates of client’s disengagement and attrition across the continuum of care highlight the need to identify and overcome the obstacles that people face at each stage of the treatment and recovery process. Peer recovery support services (PRSS) show promise in helping people initiate, pursue, and sustain long-term recovery from substance-related problems. Based on a comprehensive review of the literature, the goal of this article is to explore the possible roles of peers along the SUD care continuum and their potential to improve engagement in care by targeting specific barriers that prevent people from successfully transitioning from one stage to the next leading eventually to full recovery. A multidimensional framework of SUD care continuum was developed based on the adapted model of opioid use disorder cascade of care and recovery stages, within which the barriers known to be associated with each stage of the continuum were matched with the existing evidence of effectiveness of specific PRSSs. With this conceptual paper, we are hoping to show how PRSSs can become a complementary and integrated part of the system of care, which is an essential step toward improving the continuity of care and health outcomes.

Medicaid Expansion Increased Medications For Opioid Use Disorder Among Adults Referred By Criminal Justice Agencies

Individuals involved with the US criminal justice system have high rates of opioid use disorder (OUD) but face significant barriers to evidence-based treatment. Using 2008-17 data from the Treatment Episode Data Set-Admissions, we examined trends in receipt of medications for OUD among individuals referred by criminal justice agencies and other sources both before and after Medicaid expansion. Individuals referred by criminal justice agencies were less likely to receive medications for OUD than were those referred by other sources during our study period, although this disparity narrowed slightly after Medicaid expansion. Receipt of medications for OUD increased more for individuals referred by criminal justice agencies in states that expanded Medicaid compared with those in states that did not. Medicaid expansion may improve evidence-based treatment for individuals with criminal justice involvement and OUD, although additional policy change outside the health care sector is likely needed to reduce persistent treatment disparities.

Motivations for Treatment Engagement in a Residential Substance Use Disorder Treatment Program: A Qualitative Study

AIMS

The aim of this study was to explore perspectives on motivations for treatment engagement from substance use disorder (SUD) clients in a long-term residential rehabilitation program.

DESIGN AND METHODS

A convenience sample of 30 clients who were enrolled in a year-long SUD treatment program at a residential rehabilitation facility took part in in-depth interviews. Interview transcripts were analyzed using the directed content analysis approach.

RESULTS

Participant accounts indicated that their treatment engagement was motivated by factors that aligned with the six primary constructs of the Health Belief Model: (i) perceived susceptibility (eg, believing that their substance use required intervention and that they were prone to relapse), (ii) perceived severity (eg, substance use negatively impacted their health and harmed their close relationships), (iii) perceived benefits (eg, opportunities for a better life, reconnecting with family members and close friends, & avoiding legal consequences), (iv) perceived barriers (eg, the length of the treatment program), (v) cues to actions (eg, decisive moments, elements of the treatment program, & faith and spirituality), and (vi) self-efficacy in remaining abstinent (eg, treatment program provided them with skills and experiences to maintain long-term sobriety).

DISCUSSION

Our analysis indicates that participants' treatment engagement was linked to their beliefs regarding the severity of their substance use disorder, their treatment program's ability to help them avoid future relapse, and their own capability to act upon the strategies and resources provided by the treatment program. A theoretical understanding of these aspects can contribute to the future planning of precision interventions.

Redemption from plight: a qualitative study on reasons behind treatment decisions among Iranian male opioid users

BACKGROUND

Opioid use remains a significant cause of harm to individual health. Perceived motives are of the main factors that help lead a patient into seeking treatment voluntarily to obviate that harm. The current study expands on the literature by exploring when and how male users of opioids become motivated to voluntarily seek treatment services.

METHODS

In a qualitative study in Isfahan city from January 2018 to March 2019, 55 male participants who had already started a variety of treatment services to withdraw their dependence on opioids were recruited. Selection of participants was based on a maximum variation purposive sampling strategy. Each participant took part in a unstructured interview to identify his motives for seeking opioid use treatment. Interviews were undertaken in eight different treatment centers. An inductive thematic analysis method was used to analyze the interviews.

RESULTS

The findings highlight that Iranian male opioid users have different motivations to seek treatment. To be precise, the findings illuminate three global themes and six themes as treatment-seeking motives among the participants including; motives related to family (reason for family and reason of family), quality of life (adverse effects on personal lifestyle and health) and economic motives (financial failure and job failure).

CONCLUSIONS

The findings can improve our understanding of the motives for seeking treatment from the perspective of opioid patients who entered themselves into treatment. Particularly, these findings could help policymakers and treatment providers to better understand opioid-use patient's perceived concerns and fears as motives for treatment-seeking.

Deep Vein Thromboses in Injecting Drug Users: Meanings, Bodily Experiences, and Stigma

Deep vein thromboses (DVTs) are common sequelae of injecting drugs into the groin. We explored meanings and experiences of DVTs in a group of 19 patients from the North East of England with a DVT and in treatment for opioid use. We report three themes: (a) DVT meaning making, (b) embodied experience, and (c) Stigma. Patients attributed DVTs to groin injecting, though thought other factors were also partially responsible. Medication performed both treatment and preventive functions. The most pertinent worry was amputation. Patients recognized stopping injecting as important, but it did not necessarily occur. Stigma resulted in delayed admission to hospital and feelings of isolation; support groups might alleviate the latter. Although groin injecting was undertaken partly to avoid the censure of being a drug user, ironically, a DVT led to long-standing stigmata that were discrediting signs of that exact status.