Assessment of drug abuser treatment needs in Rhode Island

The role of consumer perspectives in estimating population need for substance use services: a scoping review

Background

A growing body of research assesses population need for substance use services. However, the extent to which survey research incorporates expert versus consumer perspectives on service need is unknown. We conducted a large, international review to (1) describe extant research on population need for substance use services, and the extent to which it incorporates expert and consumer perspectives on service need, (2) critically assess methodological and measurement approaches used to study consumer-defined need, and (3) examine the potential for existing research that prioritizes consumer perspectives to inform substance use service system planning.

Methods

Systematic searches of seven databases identified 1930 peer-reviewed articles addressing population need for substance use services between January 1980 and May 2015. Empirical studies (n = 1887) were categorized according to source(s) of data used to derive population estimates of service need (administrative records, biological samples, qualitative data, and/or quantitative surveys). Quantitative survey studies (n = 1594) were categorized as to whether service need was assessed from an expert and/or consumer perspective; studies employing consumer-defined need measures (n = 217) received further in-depth quantitative coding to describe study designs and measurement strategies.

Results

Almost all survey studies (96%; n = 1534) used diagnostically-oriented measures derived from an expert perspective to assess service need. Of the small number (14%, n = 217) of survey studies that assessed consumer’s perspectives, most (77%) measured perceived need for generic services (i.e. ‘treatment’), with fewer (42%) examining self-assessed barriers to service use, or informal help-seeking from family and friends (10%). Unstandardized measures were commonly used, and very little research was longitudinal or tested hypotheses. Only one study used a consumer-defined need measure to estimate required service system capacity.

Conclusions

Rhetorical calls for including consumer perspectives in substance use service system planning are belied by the empirical literature, which is dominated by expert-driven approaches to measuring population need. Studies addressing consumer-defined need for substance use services are conceptually underdeveloped, and exhibit methodological and measurement weaknesses. Further scholarship is needed to integrate multidisciplinary perspectives in this literature, and fully realize the promise of incorporating consumer perspectives into substance use service system planning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2153-z) contains supplementary material, which is available to authorized users.

CADS: Two Short Screeners for Cocaine and Heroin Dependence among Arrestees

In view of the prevalence of drug use among criminals, the assessment of drug dependence is a valuable responsibility of the criminal justice system. Obtaining accurate and expeditious assessments, however, has traditionally been a difficult goal to achieve because of limited time and resources. While several scales have been developed to screen for drug dependence, none have been developed for specific drugs of abuse within criminal populations. We used data from the Substance Abuse Need for Treatment among Arrestees (SANTA) study in Baltimore to develop screening instruments for cocaine and heroin dependence. The SANTA interview is a module of questions that diagnoses alcohol and other drug (AOD) abuse and dependence according to the Diagnostic and Statistical Manual of Mental Disorders, third edition-revised (DSM-III-R) criteria. Extensive inquiries about AOD-using behaviors are made using a computer-assisted module of the Diagnostic Interview Schedule, Version III-Revised (DIS-III-R), a structured interview that operationalizes the nine DSM-III criteria to diagnose substance abuse and dependence and estimate treatment need based on interview responses. The Center for Substance Abuse Research (CESAR) Arrestee Drug Screener (CADS) developed in the current study utilizes two sets of three questions each from the DIS-III-R for the purpose of identifying cocaine and heroin dependence among arrestees. The high sensitivities and negative predictive values of the CADS make them especially useful for identifying those arrestees most likely to be diagnosed dependent on the respective drug. Implications for using the screeners with criminal populations are discussed.

Sources of Error in Substance Use Prevalence Surveys

Population-based estimates of substance use patterns have been regularly reported now for several decades. Concerns with the quality of the survey methodologies employed to produce those estimates date back almost as far. Those concerns have led to a considerable body of research specifically focused on understanding the nature and consequences of survey-based errors in substance use epidemiology. This paper reviews and summarizes that empirical research by organizing it within a total survey error model framework that considers multiple types of representation and measurement errors. Gaps in our knowledge of error sources in substance use surveys and areas needing future research are also identified.

Estimating the prevalence of xenophobia and anti-Semitism in Germany: A comparison of randomized response and direct questioning

An experimental CATI-survey (N=2041), asking sensitive questions about xenophobia and anti-Semitism in Germany, was conducted to compare the randomized response technique (RRT) and the direct questioning technique. Unlike the vast majority of RRT surveys measuring the prevalence of socially undesirable behaviors, only few studies have explored the effectiveness of the RRT with respect to the disclosure of socially undesirable opinions. Results suggest that the RRT is an effective method eliciting more socially undesirable opinions and yielding more valid prevalence estimates of xenophobia and anti-Semitism than direct questioning ('more-is-better' assumption). Furthermore, the results indicate that with increasing topic sensitivity, the benefits of using the RRT also increase. Finally, adapted logistic regression analyses show that several covariates such as education and generalized trust are related to the likelihood of being prejudiced towards foreigners and Jews.

Projecting Adolescent Prevention and Treatment Need: A Novel Application Utilizing the Communities That Care Data in the State of Kansas

This study projects substance abuse and dependence prevalence rates based on the number of early problem behaviors (tobacco, alcohol and marijuana use, and arrests prior to age 15) reported by youth who have taken part in eleven administrations of the annual Kansas Communities That Care survey following a model developed by McGue and Iacono (2005). The probability of males and females developing a substance abuse or dependence disorder at age 17 and 20 was assigned to each respondent. Projections were mapped to show county and statewide dispersions for planning purposes. Projected numbers were much higher than expected. In addition to young adult treatment need, the implications for prevention service planning became readily apparent. The findings highlight missed opportunities for indicated prevention and early intervention services and are further discussed in the context of how early intervention might alleviate demand on the treatment system as adolescents progress into young adulthood.

Unmet need for Substance Abuse Treatment of Adults in Massachusetts

This article presents a methodology to estimate the size and cost of eliminating unmet need for substance abuse treatment services among adults who have clinically significant substance use disorders, and applies the approach to Massachusetts' information. Unmet treatment needs were derived using a statewide household telephone survey of 7,251 Massachusetts residents aged 19 and older conducted in 1996-1997, and an index of treatment mix and cost information from state and Medicaid financial data. The study estimates that 39,450 adult state residents (0.81% of the total sample) had a clinically significant past-year substance use disorder, but had not received treatment in the past year. Providing substance abuse treatment and outreach services to them would have required an additional cost of approximately 109 million dollars (17 dollars per capita), of which the state's payer of last resort, the Massachusetts Department of Public Health Bureau of Substance Abuse Services (BSAS), would need to fund 31 million dollars (5 dollars per capita). The share paid by BSAS (28%) would represent an increase of 42% over its current spending. This paper quantifies an important but sometimes overlooked objective of managed care: to improve access for substance abusers who need but do not seek treatment.

Substance abuse treatment needs and access in the USA: interstate variations

AIMS

This study investigated interstate substance abuse treatment needs and access in the USA.

DESIGN

After assessing the validity of recently developed survey and indicator measures, the study analysed the geographic distribution and nature of state substance abuse treatment needs. Substance abuse treatment utilization index scores were regressed on the need measurements to identify differences among state populations in treatment access.

FINDINGS

The interstate substance abuse treatment need measures had evidence of reliability and construct validity. Treatment needs clustered in stable, distinct geographic patterns. The most severe problems, primarily reflecting alcoholism, were in the west. Drug and alcohol substance use disorders and related problems were not significantly correlated at this level of aggregation. There was evidence of regionalization of the drug-of-choice mix in treatment admissions. Only 21% of the variations in state treatment utilization rates stemmed from the prevalence of substance use disorders and related problems. The biggest treatment gaps were in the south and south-west, regions with large minority populations.

CONCLUSIONS

Development of interstate survey and indicator measures of treatment needs has created new opportunities to broaden our understanding of substance abuse epidemiology and treatment access in the USA. The nature and severity of drug and alcohol problems vary from state to state, but the interstate disparities in treatment services remain even after variations in treatment need have been discounted. Further research is needed to understand the causes of these differences in treatment access.

"Who gets in?" Recruitment and screening processes of outpatient substance abuse trials

A brief telephone-screening interview was conducted with 1759 callers seeking treatment for substance abuse at the Treatment Research Clinic (TRC) over a 16-month period. The purpose of this study was to examine the effectiveness of various recruitment methods in attracting eligible participants and to identify screening variables that characterized eligible and ineligible callers. Callers referred by friends and family were more likely to be eligible than callers from other referral sources. Callers seeking treatment for cocaine abuse who reported more severe alcohol/substance problems were more likely to be eligible for treatment protocols, while those with severe problems in other psychosocial areas (legal, medical, and psychiatric) were more often excluded. Alcohol- and nicotine-dependent callers reporting severe alcohol problems were more likely to be eligible but otherwise were not different from callers who were ineligible. The effectiveness of recruitment methods may not be the same for different types of substance use disorders. This study underscores the importance of having a sensitive screening assessment for recruiting a homogeneous yet representative sample for outpatient substance abuse clinical trials.

Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations

OBJECTIVES

This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment.

METHODS

Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990, 1995, and 2000. Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients.

RESULTS

In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3).

CONCLUSIONS

Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs.

Identifying substance abuse treatment gaps in substate areas

Investigating concerns about uneven utilization of health services, especially affecting disadvantaged high-risk populations, the authors constructed composite indexes for identifying substance abuse treatment gaps in Rhode Island towns and multi-town planning areas. The Drug, Alcohol, and Substance Abuse Need Indexes combined multiple-year rates of substance-related deaths, hospital discharges, and arrests. These indicators were reliable and possessed convergent validity; the composite indexes were also reliable and had construct validity. Regression of treatment admissions rates on town Substance Abuse Need Index scores revealed that some areas had relative gaps in treatment services. Having an objective and validated method for identifying treatment gaps could help treatment planners ensure equal access to services throughout the state. Reducing travel to treatment facilities can increase treatment utilization and treatment retention.

Injection drug users: hospital care and charges

Injection drug users have high rates of hospital use, however, the specific contribution of injection-related infections to hospitalization has never been determined. After reviewing 92 consecutive admissions of HIV-negative injection drug users to Rhode Island Hospital in 1998, we found that 49% were related to infections and an additional 24% were due to the biological effects of the injected drug. Admissions that were for injection-related infections were significantly more costly than other admissions of injection drug users ($13958 vs. $7906). We conclude that considerable savings may result from preventative care of this population, including instruction in skin-cleaning techniques.

Remission from drug abuse over a 25-year period: patterns of remission and treatment use

OBJECTIVES

Using an epidemiologically obtained sample, we examined patterns of illicit drug use, abuse, and remission over a 25-year period and recent treatment use.

METHODS

The surviving members of the cohort (n = 841), previously surveyed in 1972 and 1974, comprised 3 subsamples of Vietnam War enlisted men and civilian controls. Retrospectively obtained year-to-year measures from the 1996-1997 survey included use and remission of sedatives, stimulants, marijuana, cocaine, and opiates, as well as substance abuse and psychiatric treatment use.

RESULTS

Relatively stable patterns of frequent use in adulthood were found, with the mean duration from initiation to the last remission ranging from 9 to 14 years. A majority attempted to quit; however, most did not use traditional drug treatment in their last attempts. Fewer than 9% of the then-current drug users were treated in inpatient or outpatient settings at the time of data collection.

CONCLUSIONS

Most drug abusers who had started using drugs by their early 20s appeared to gradually achieve remission. Spontaneous remission was the rule rather than the exception. Nonetheless, considerable unmet needs existed for those who had continued use into middle age.

A survey of state insurance mandates covering alcohol and other drug treatment

This article reports the results of a survey of health insurance mandate legislation for alcohol and other drug treatment in the 50 states through spring 1991. A total of 23 states (including the District of Columbia) requires insurance carriers to provide coverage for alcohol and other drug treatment. This paper compares the provisions in these states at the present time and contrasts these provisions with those in effect in 1981. The paper concludes with a discussion of the policy objectives states pursue through enactment of such legislation and the outcomes brought about by the mandates.

Drug treatment experiences: rural and urban comparisons

This study sought to investigate treatment-seeking behaviors among drug users in rural populations and how they compare to their urban counterparts. Data for this analysis were drawn from the Miami and Immokalee sites of the National Institute on Drug Abuse's Cooperative Agreement Program for AIDS outreach/intervention research study targeting high-risk out-of-treatment injection drug users and crack smokers. Findings indicate that Miami subjects were 2.57 times more likely to have been in drug treatment compared to their rural counterparts. This differential may be explained in terms of the availability, accessibility, and acceptability of health care services.

Rural and urban problem drinkers in six Southern states

In 1994-1997 we conducted a four-wave longitudinal study of rural and urban problem drinkers in six Southern United States states to examine rural/urban differences in predictors of service use and course of drinking. This report describes early rural/urban differences from a brief interview with over 3,000 community individuals and among 525 identified problem drinkers. Overall, we found rural/urban differences in alcohol consumption at the community level but only demographic differences among problem drinkers. Our newly developed screening interview for alcohol disorders had excellent agreement (kappa = 0.72) for lifetime disorders and good agreement (kappa = 0.53) for recent disorders against structured diagnostic interviews for DSM-IV criteria.

Accessing Drug-Abuse Treatment: Perceptions of Out-of-Treatment Injectors

The Presidential Commission on the Human Immunodeficiency Virus Epidemic (1988) developed a 10-year plan in 1987 that recommended: “Expanded drug abuse treatment programs sufficient to admit all IV drug users who desired services and, until that occurred, short-term detoxification and low-dose methadone for those on waiting lists.” This study presents data collected from a sample of 2,613 out-of-treatment and non-incarcerated injection drug users in 21 U.S. cities to examine their drug-treatment access during the past year. Analyses on injectors who tried but were unable to enter treatment revealed that program-based reasons (e.g., no room, too costly, or stringent admission criteria) are the most commonly given barriers to drug treatment (72%). However, a notable number of injectors (20%) also reported that individual-based reasons are important for not accessing drug treatment. Injectors giving program- and individual-based reasons for not entering treatment are profiled using logistic regression.

Are Telephone Surveys Suitable for Studying Substance Abuse? Cost, Administration, Coverage and Response Rate Issues

Substance-abuse telephone surveys have become increasingly popular; however, the methodological literature has focused solely on potential disadvantages of the method when compared to face-to-face surveys. Striving for greater balance, this paper examines the potential advantages (lower cost, greater security and privacy, and easier administration) and disadvantages (noncoverage, lower response rates, and lower validity). Existing evidence suggests that the disadvantages typically have a small impact on prevalence estimates. When there is a risk of substantial bias, researchers should employ available techniques for minimizing it. On balance, the telephone survey's advantages appear to outweigh the disadvantages for many research problems, but enhanced designs are needed to realize the method's full potential in this substantive area.

Collecting substance use data with an anonymous mailed survey

Because mailed surveys minimize personal contact, they are useful for collecting sensitive data on substance use, as long as the problems of achieving adequate response rates can be conquered. To address these issues, we report on an anonymous mailed survey of substance use with a 78% response rate, including data collection and survey methods. Analysis of sociodemographic effects on responding found certain groups required additional contacts. Substance use estimates were not affected by non-response bias, suggesting that anonymous mailed surveys can be a feasible means of collecting data on substance use.

Managed care of substance abuse disorders. Implications for generalist physicians

Given the rapidly changing landscape of both private and public health plan programs, it is foolhardy to suggest that a definitive characterization of managed care and substance abuse issues can be made. Among other topics, this article discusses goals of managed care organizations, managed care models, and physicians' roles in managed care.

Test-retest reliability of psychoactive substance abuse and dependence diagnoses in telephone interviews using a modified Diagnostic Interview Schedule-Substance Abuse Module

The test-retest reliability of lifetime substance abuse and dependence diagnoses obtained by telephone interviewers was investigated. Trained personnel administered two identical interviews based on a modified Diagnostic Interview Schedule-Substance Abuse Module (DISSAM) approximately a week apart for 100 respondents, of whom 55 were receiving alcohol or other drug treatment and 45 and randomly selected from residential households in one Michigan county. The uncorrected agreement for all lifetime dependence diagnoses exceeded 93% for all six categories assessed and the more conservative chance corrected agreement (Cohen's Kappa coefficient kappa) was .92 (alcohol),.76 (marijuana),.87 (cocaine), and .71 (other opiates). Kappa coefficients for hallucinogens and heroin dependence could not be calculated due to low (i.e., 5% or less) base rates. Likewise, kappa was calculated only for a single abuse diagnosis, alcohol, with kappa = .42 and 95% agreement. In the interpretation of kappa, the standard applied was: kappa ranging from .41 to .60 represented moderate agreement, kappa ranging from .61 to .80 represented substantial agreement, and kappa ranging from .81 to 1.00 represented excellent agreement. Thus, test-retest reliability was excellent for lifetime alcohol and cocaine dependence and was substantial for lifetime marijuana and other opiates dependence. These results indicate that lifetime psychoactive substance abuse diagnoses can be obtained fairly reliably over the telephone using trained lay interviewers.

Statewide substance abuse prevention planning

The State of Rhode Island contracted with the authors to prepare a statewide, comprehensive substance abuse prevention plan. The literature review revealed a lack of research on statewide planning for prevention services. To obtain data for Rhode Island's plan, the authors conducted a family of studies including synthetic estimation, key informant interviews, a telephone survey of agency directors, program budget analysis, construction of a statistical index for estimating the optimal geographic allocation of prevention dollars, and a review of General Laws regarding tobacco, alcohol, and other drugs. Their recommendations include the increased funding and coordination of prevention services, allocating services according to need rather than population size, greater use of social policy as a prevention tool, and a shift in primary prevention programming from senior high to lower grades and in program emphasis from information-education to psychosocial programs.

On the construction of a relative needs assessment scale

The Social Dysfunction Scale, originally framed by Simeone et al., is a major first step in the introduction of objectivity to a complex subject often guided by political concerns rather than empirical findings. However, it is too heavily influenced by population sizes of the geographic units. The Relative Needs Assessment Scale proposed here is more flexible and corrects that problem by using weights that set a balance between the burden of the substance use(r) problem and the size of the "population at risk" in the geographic unit. Assuming that a fairly good mix of indicators is identified for substance use(r) problems, the alternative scale provides a better estimate of relative needs for resources.

Drug treatment on demand--not

Drug treatment on demand, appropriate and affordable drug treatment for injection drug users who are "ready" to enter a program, is a humane approach to drug treatment services and an important mechanism to halt the spread of HIV. However, drug treatment on demand is not a reality in the United States. In fact, due to funding cuts at federal, state, and local levels, entry into drug treatment programs has become increasingly more difficult over the past decade. In a NIDA-funded ethnographic study of methadone maintenance, i.v. drug use and AIDS, 70 heroin addicts who were out of treatment and actively seeking methadone maintenance were interviewed. In life-history interviews, the drug users described barriers to treatment, waiting-list experiences, and the impact of these experiences on their drug use, drug-using behavior, and emotional well-being. Respondents used many mechanisms to cope with the lack of availability of drug treatment slots, some of which have increased their risk of exposure to and spread of HIV. These findings indicate the need for an increase in the availability of subsidized methadone maintenance treatment slots "on demand" if individuals are to decrease their drug use and their high-risk behaviors. Drug treatment on demand is more than politically correct rhetoric. It is a necessary ingredient in reducing the harm caused by the use of illegal drugs.

The prescription of methadone for opiate dependence in Australia, 1985-1991

OBJECTIVE

To describe the rates and patterns of prescription of methadone for opiate dependence in Australia from 1985 to 1991.

DESIGN

Data on the numbers of Australians prescribed methadone in States and Territories were used to calculate prevalence rates of prescription of methadone.

RESULTS

In 1985, Queensland had the highest rate of prescription of methadone. After the establishment of the National Campaign Against Drug Abuse, rates increased in most jurisdictions. Assessment procedures and prescribing practices, such as private prescription of methadone, appear to have markedly affected rates of prescription in some States.

CONCLUSION

Large differences in rates of methadone prescription have occurred in Australian States and Territories. There are inadequate data to explain how rates of prescription are related to the prevalence of opiate use. Investigations of prevalence of injecting opiate use, demand for treatment and clinic practices are needed to explain these patterns fully.

Prevalence Estimation and Policy Formulation

Prevalence estimation has a potentially important role in drug policy decision making. To date, however, it has played only a modest role in decisions at the national level, though it has come to be important in the rhetoric of national drug policy. This limited influence arises from the limited capacities and credibility of the estimates on the one hand and the highly moralistic nature of the policy process surrounding the illicit drug issue on the other. The available numbers are developed either systematically from data sources that have low credibility (self-report) or are developed less systematically from sources that simply are not well understood. Estimates of the number of problematic drug users are most likely to have a significant role in policy making in the near future.

Correlates of HIV Seropositivity among Injection Drug Users Not in Treatment

In 1989, from May to December, 1,440 injection drug users (IDUs) in Newark and Jersey City, not enrolled in treatment, were recruited by outreach to storefront offices, where they were interviewed about AIDS-risk behaviors and tested for antibodies to HIV. Information was gathered on drug use and sexual patterns, health, criminality and demographics. Data from 1,278 IDUs (88.75%) were analyzed; 667 (52.5%) tested HIV-antibody positive. Using univariate and multivariate analysis, thirteen variables were identified that were significantly and independently associated with seropositivity, including years since first drug injection, injecting mixed heroin and cocaine, frequent injection of cocaine by itself, no “crack” use, no noninjected heroin use, time in jail, abuse of glue or paint thinner, absence of sexual activity, subjects' global rating of their own AIDS risk, health history, gender, race and education. Implications for HIV risk assessment in other regions and for the development of interventions are discussed.

Implementation issues and techniques in randomized trials of outpatient psychosocial treatments for drug abusers: recruitment of subjects

We reviewed nine randomized clinical trials of outpatient psychosocial treatments for drug abuse to ascertain implementation problems and solutions that the researchers developed. The most common problem was subject recruitment. Inadequate recruitment can disrupt a project's timetable, preoccupy its staff, reduce the trial's ability to detect treatment differences, and perhaps result in the trial's abandonment. The causes of recruitment problems include the need for large samples and multiple eligibility criteria, subject reluctance to be a "guinea pig," low client treatment motivation, client dislike of research procedures, clinicians' distrust of research, and difficulties collaborating with treatment agencies. Solutions include realistic assessment of the target population's size, use of mass media, statistical adjustments to minimize unnecessary sample exclusions, variable treatment assignment ratios, and prevention of common collaboration difficulties.