Adult use cannabis legalization and cannabis use disorder treatment in California, 2010-2021

INTRODUCTION

Many nations and jurisdictions have legalized non-medical adult use of cannabis, or are considering doing so. This paper contributes to knowledge of adult use legalization's associations with cannabis use disorder (CUD) treatment utilization.

METHODS

This study collected data from a dataset of all publicly funded substance use disorder treatment delivered in California from 2010 to 2021 (1,460,066 episodes). A logistic regression model estimates adult use legalization's impacts on CUD treatment utilization using an individual-level pre-post time series model, including individual and county-level characteristics and county and year-fixed effects.

RESULTS

Adult use legalization was associated with a significant decrease in the probability of admission to CUD treatment (average marginal effect (AME): -0.005, 95 % CI: -0.009, 0.000). Adult use legalization was also associated with a decrease in the probability of admission to CUD treatment for males (AME: -0.025, 95 % CI: -0.027, -0.023) Medi-Cal beneficiaries (AME: -0.025, 95 % CI: -0.027, -0.023) adults ages 21+ (AME: -0.011, 95 % CI: -0.014, -0.009) and Whites (AME: -0.012, 95 % CI: -0.015, -0.010), and an increase in the probability of admission to CUD treatment for patients referred from the criminal justice system (AME: 0.017, 95 % CI: 0.015, 0.020) and Blacks (AME: 0.004, 95 % CI: 0.000, 0.007) and Hispanics (AME: 0.009, 95 % CI: 0.006, 0.011).

CONCLUSIONS

Adult use legalization is associated with declining CUD treatment admissions, even though cannabis-related problems are becoming more prevalent. Policies and practices that protect public health, and engage people with CUD in treatment are needed.

Recovery incentives program: California's contingency management benefit

OBJECTIVE

The role of methamphetamine and cocaine use in California's drug poisoning (overdose) crisis has dramatically increased in the past five (5) years and has disproportionately affected American Indian, Alaska Native, and Black Californians. No FDA-approved medications currently exist for the treatment of individuals with stimulant use disorder (StimUD). Outside the Veteran's Administration, the Recovery Incentives Program: California's Contingency Management Benefit is the first large scale implementation of contingency management (CM). CM is the behavioral treatment with the most evidence and largest effect sizes for StimUD.

METHODS

The Program uses a CM protocol where participants can receive a maximum of $599 over a six-month period, contingent upon 36 stimulant-negative urine test results. Urine tests are conducted using a set of approved, CLIA-waived, point-of-care urine drug tests (UDTs). To ensure fidelity to the CM protocol and to prevent fraud, waste, and abuse, all aspects of incentive accounting and distribution are managed electronically via a custom-developed software system. Incentive distribution utilizes electronic gift cards. A significant innovation of the project is the conceptualization of the CM Coordinator, a designated and highly trained and supervised individual responsible for all aspects of CM operation in a specific site.

RESULTS AND CONCLUSIONS

The California Department of Health Care Services contracted with UCLA to develop and implement a robust evaluation of the Program; goals include evaluating the effectiveness of real-world implementation and facilitating quality improvement. The project will likely significantly impact the use of CM for StimUD nationally and may well reduce stimulant-related drug poisoning deaths.

The Effect of the Drug Medi-Cal Organized Delivery System 1115 Demonstration Waiver on Substance Use Disorder Treatment Access: Evidence from California

BACKGROUND

In August 2015, the California Department of Health Care Services created the Drug Medi-Cal Organized Delivery System 1115 demonstration waiver (DMC-ODS waiver) to improve service delivery to Medi-Cal-eligible individuals with a substance use disorder (SUD). We examine if implementing the DMC-ODS waiver across California counties improved patient access to SUD treatment services.

METHODS

We use administrative data from 2016 to 2020 from a reporting system for all publicly-funded SUD treatment services delivered in California and employ difference-in-differences and event study empirical strategies exploiting the differential timing of DMC-ODS waiver adoption across counties.

RESULTS

Event study analyses show that eleven or more months after the introduction of the DMC-ODS waiver, the number of unique patient admissions significantly increase by nearly 20%. Residential treatment admissions significantly increase by roughly 25% in all months post-waiver introduction.

CONCLUSIONS

This study provides valuable information for policymakers about implementing 1115 waivers, and the important public health implications. California's DMC-ODS waiver has demonstrated that 1115 waivers similar to it can likely increase access to SUD treatment.

Medical conditions of primary care patients with documented cannabis use and cannabis use disorder in electronic health records: a case control study from an academic health system in a medical marijuana state

BACKGROUND

Approximately 3.8% of adults worldwide have used cannabis in the past year. Understanding how cannabis use is associated with other health conditions is crucial for healthcare providers seeking to understand the needs of their patients, and for health policymakers. This paper analyzes the relationship between documented cannabis use disorders (CUD), cannabis use (CU) and other health diagnoses among primary care patients during a time when medical use of marijuana was permitted by state law in California, United States of America.

METHODS

The study utilized primary care electronic health record (EHR) data from an academic health system, using a case-control design to compare diagnoses among individuals with CUD/CU to those of matched controls, and those of individuals with CUD diagnoses with individuals who had CU otherwise documented. Associations of documented CU and CUD with general medical conditions and health conditions associated with cannabis use (both medical and behavioral) were analyzed using conditional logistic regression.

RESULTS

Of 1,047,463 patients with ambulatory encounters from 2013-2017, 729 (0.06%) had CUD diagnoses and 3,731 (0.36%) had CU documented in their EHR. Patients with documented CUD and CU patients had significantly (p < 0.01) higher odds of most medical and behavioral diagnoses analyzed. Compared to matched controls, CUD-documented patients had highest odds of other substance use disorders (OR = 21.44: 95% CI 9.43-48.73), any mental health disorder (OR = 6.99; 95% CI 5.03-9.70) social anxiety disorder (OR = 13.03; 95% CI 2.18-77.94), HIV/AIDS (OR = 7.88: 95% CI 2.58-24.08), post-traumatic stress disorder (OR = 7.74: 95% CI 2.66-22.51); depression (OR = 7.01: 95% CI 4,79-10.27), and bipolar disorder (OR = 6.49: 95% CI 2.90-14.52). Compared to matched controls, CU-documented patients had highest odds of other substance use disorders (OR = 3.64; 95% CI 2.53-5.25) and post-traumatic stress disorder (OR = 3.41; 95% CI 2.53-5.25). CUD-documented patients were significantly more likely than CU-documented patients to have HIV/AIDS (OR = 6.70; 95% CI 2.10-21.39), other substance use disorder (OR = 5.88; 95% CI 2.42-14.22), depression (OR = 2.85; 95% CI 1.90-4.26), and anxiety (OR = 2.19: 95% CI 1.57-3.05) diagnoses.

CONCLUSION

The prevalence of CUD and CU notation in EHR data from an academic health system was low, highlighting the need for improved screening in primary care. CUD and CU documentation were associated with increased risk for many health conditions, with the most elevated risk for behavioral health disorders and HIV/AIDS (among CUD-documented, but not CU-documented patients). Given the strong associations of CUD and CU documentation with health problems, it is important for healthcare providers to be prepared to identify CU and CUD, discuss the pros and cons of cannabis use with patients thoughtfully and empathically, and address cannabis-related comorbidities among these patients.

Homelessness and publicly funded substance use disorder treatment in California, 2016-2019: Analysis of treatment needs, level of care placement, and outcomes

INTRODUCTION

Both homelessness and substance use have increased in recent years. People experiencing homelessness (PEH) are at increased risk for health problems and early mortality, both of which can be exacerbated by substance use disorders (SUD). Specialty SUD treatment is likely needed to address substance use among PEH, and more than 232,000 PEH received treatment from U.S. publicly funded SUD programs in 2015. The objective of this paper is to develop a better understanding of the SUD services that PEH receive in publicly funded treatment programs by (1) describing the characteristics and needs of the PEH population served in publicly funded SUD treatment programs, compared to non-PEH populations; (2) determining if differences exist in treatment placement (level of care) for PEH and non-PEH; and (3) gauging how successful programs are in treating PEH compared to non-PEH.

METHODS

Observational study using a two-way fixed effect model to determine associations among homelessness, retention, and outcomes among Medicaid beneficiaries receiving SUD treatment in California from 2016 to 2019 (n = 638,953). The study team used ordinary least squares (OLS) regression to measure the degree to which homelessness was associated with baseline characteristics, SUD services received, and treatment outcomes.

RESULTS

PEH were significantly more likely than non-PEH to be having methamphetamine or heroin as their primary substance. PEH had greater frequency of primary substance use prior to entering treatment, greater ER and hospital utilization, more criminal justice involvement, and greater prevalence of mental health diagnoses and unemployment. PEH were 9.82% more likely than non-PEH to receive residential treatment and 7.11% less likely than non-PEH to receive treatment intensive outpatient modalities. Homelessness was associated with an 11.90% decrease in retention, and a 19.40% decrease in successful discharge status. These trends were consistent across outpatient, intensive outpatient, and residential modalities.

CONCLUSIONS

Developing SUD treatment capacity and housing supports can improve treatment outcomes for PEH. Potential strategies to improve SUD services for PEH include providing more contingency management, opioid pharmacotherapies, programming designed to treat individuals with co-occurring mental health disorders, and resources for housing options that can support PEH in their recovery.

Opening the “black box”: Four common implementation strategies for expanding the use of medications for opioid use disorder in primary care

Background:

Despite the persistent increase in overdose deaths, access to medications for opioid use disorders remains limited. Recent federal funding aimed at increasing access prompts a need to understand if implementation strategies improve access.

Methods:

This is an analysis of data from 174 primary care clinics enrolled in a state-wide medications for opioid use disorders (MOUD) implementation effort in California. We examined clinic use of one of four implementation strategies: learning collaboratives, Project Extension for Community Health care Outcomes (ECHO), didactic webinars, and clinical skills trainings. The primary implementation outcome was categorical change in new patients prescribed buprenorphine. Univariate and multivariate logistic regressions were used to determine the impact of clinic attendance in all or individual implementation strategies, respectively, on patient growth.

Results:

Clinics attending learning collaboratives, Project ECHO, and clinical skills trainings had significantly higher odds of patient growth (odds ratio [OR] = 3.56; 95% confidence interval [CI] = 1.78, 7.10, p < .001), (OR = 3.39; 95% CI = 1.59, 7.24, p < .01), (OR = 3.90, 95% CI = 1.64, 9.23, p < .01) than non-attending clinics. The impact of attendance at learning collaboratives (OR = 5.81, 95% CI = 1.89, 17.85; p < .01), didactic webinars (OR = 3.59; 95% CI = 1.04, 12.35; p < .05), and clinical skills trainings (OR = 3.53, 95% CI = 1.06, 11.78, p < .05) on patient growth was greater for Federally Qualified Health Centers. When comparing strategies in multivariate models, only the relationship between learning collaborative attendance and new patients prescribed buprenorphine remained significant (OR = 2.57; 95% CI = 1.12, 5.88; p < .05).

Conclusions:

This study reported on a large, statewide, implementation-as-usual project offering four typical implementation strategies. Clinic attendance at learning collaboratives, a multi-component strategy, had the most consistent impact on new patients prescribed buprenorphine. These results suggest that while a broad array of strategies was initially reasonable, optimizing the selection of implementation strategies could be more effective.

Plain Language Summary

Access to life-saving medications for opioid use disorder, such as buprenorphine, remains limited despite strong evidence of effectiveness. Systems and organizations often select from a variety of implementation strategies aimed at expanding access to these medications. However, scant research exists to enable these organizations to select the most effective and efficient strategies. Our study—within a large state-wide system of care—examined the impact of primary care clinic attendance in four common implementation strategies on new patients prescribed buprenorphine. Learning collaboratives were the strategy that most consistently improved outcomes. These results highlight the challenges to strategy selection inherent in implementation-as-usual systems-level approaches. The field needs evidence-based information on which implementation strategies are most likely to yield desired implementation outcomes.

Racial dynamics among clients in a residential substance use disorder treatment program in South Los Angeles and its impact on clients' treatment experiences

This study seeks to investigate racial dynamics among clients in a female-only residential substance use disorder treatment facility in South Los Angeles and its effects on treatment experiences. Clients were interviewed about their interracial interactions, perceptions of clients of races and ethnicities different from their own and how racial dynamics might affect their experiences in treatment. Nine interviews were conducted and analyzed using thematic analysis. Participants recounted that racial differences do not play a significant role in their treatment experiences, although racial identities shape social group formation. Motivation to recover from addiction and other shared lived experiences facilitate interracial harmony.

Preliminary results of the evaluation of the California Hub and Spoke Program

In August 2017, California launched the Hub and Spoke Program to address the growing number of opioid overdose deaths in the state. The program connects opioid treatment programs ("hubs") with office based opioid treatment settings, like primary care clinics ("spokes") to build a network of treatment expertise and referral resources. A key objective of this program is to expand access to medications for opioid use disorders (MOUD), with a particular focus on getting more buprenorphine into spokes. This article describes the preliminary results of the evaluation of the California Hub and Spoke program. Using a mixed methods approach, this portion of the evaluation measures changes in numbers of MOUD patients and providers, and barriers and facilitators to implementation. Findings reveal that, in the first 15 months of the program, 3480 new patients started buprenorphine in 118 spokes, increasing treatment initiations by 94.7% over baseline. The number of waivered spoke providers also increased 52.4% to 268. Although these data demonstrate promising growth in the network, challenges to expanding treatment access remain. Provider activity was among the most notable. Despite growth in the number of spoke providers with waivers to prescribe buprenorphine, only 68.7% (n = 184) were actively prescribing to patients. A survey of providers found that those who were not yet using their waivers lacked the confidence and mentorship they needed to prescribe. Provider knowledge and attitudes toward MOUD, fear of legal consequences, and limited patient outreach were also contributing factors. Recommendations for strengthening Hub and Spoke program implementation include facilitating mentor linkage for prescribers, expanding the support offered to spoke providers, and offering additional training and technical assistance aimed at provider stigma. Efforts to address these recommendations are described in a companion paper (Miele et al., under review).

Cost-Effectiveness of Publicly Funded Treatment of Opioid Use Disorder in California

BACKGROUND

Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations.

OBJECTIVE

To determine the cost-effectiveness of OAT for all treatment recipients compared with the observed standard of care for patients presenting with opioid use disorder to California's publicly funded treatment facilities.

DESIGN

Model-based cost-effectiveness analysis.

DATA SOURCES

Linked population-level administrative databases capturing treatment and criminal justice records for California (2006 to 2010); published literature.

TARGET POPULATION

Persons initially presenting for publicly funded treatment of opioid use disorder.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Immediate access to OAT with methadone for all treatment recipients compared with the observed standard of care (54.3% initiate opioid use disorder treatment with medically managed withdrawal).

OUTCOME MEASURES

Discounted quality-adjusted life-years (QALYs) and discounted costs.

RESULTS OF BASE-CASE ANALYSIS

Immediate access to OAT for all treatment recipients costs less (by $78 257), with patients accumulating more QALYs (by 0.42) than with the observed standard of care. In a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, total lifetime savings for this cohort could be as high as $3.8 billion.

RESULTS OF SENSITIVITY ANALYSIS

99.6% of the 2000 simulations resulted in lower costs and more QALYs.

LIMITATION

Nonrandomized delivery of OAT or medically managed withdrawal.

CONCLUSION

The value of publicly funded treatment of opioid use disorder in California is maximized when OAT is delivered to all patients presenting for treatment, providing greater health benefits and cost savings than the observed standard of care.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

Estimating State Transitions for Opioid Use Disorders

AIM

The aim was to estimate transitions between periods in and out of treatment, incarceration, and legal supervision, for prescription opioid (PO) and heroin users.

METHODS

We captured all individuals admitted for the first time for publicly funded treatment for opioid use disorder (OUD) in California (2006 to 2010) with linked mortality and criminal justice data. We used Cox proportional hazards and competing risks models to assess the effect of primary PO use (v. heroin) on the hazard of transitioning among 5 states: (1) opioid detoxification treatment; (2) opioid agonist treatment (OAT); (3) legal supervision (probation or parole); (4) incarceration (jail or prison); and (5) out-of-treatment. Transitions were conditional on survival, and death was modeled as an absorbing state.

RESULTS

Both primary PO (n = 11,733) and heroin (n = 19,926) users spent most of their median 2.3 y of observation out of treatment. Primary PO users were significantly younger (median age 30 v. 34 y), and a higher percentage were female (43.1% v. 31.5%; P < 0.001), white (74.6% v. 63.1%; P < 0.001), and had completed high school (31.8% v. 18.9%; P < 0.001). When compared to primary heroin users, PO users had a higher hazard of transitioning from detoxification to OAT (Hazard Ratio (HR), 1.65; 95% CI, 1.54 to 1.77), and had a lower hazard of transitioning from out-of-treatment to either detoxification (0.75 [0.70, 0.81]) or OAT (0.90 [0.85, 0.96]).

CONCLUSION

Our findings can be applied directly in state transition modeling to improve the validity of health economic evaluations. Although PO users tended to remain in treatment for longer durations than heroin users, they also tended to remain out of treatment for longer after transitioning to an out-of-treatment state. Despite the proven effectiveness of time-unlimited treatment, individuals with OUD spend most of their time out of treatment.

The costs of crime during and after publicly funded treatment for opioid use disorders: a population-level study for the state of California

BACKGROUND AND AIMS

Treatment for opioid use disorders (OUD) reduces the risk of mortality and infectious disease transmission; however, opportunities to quantify the potential economic benefits of associated decreases in drug-related crime are scarce. This paper aimed to estimate the costs of crime during and after periods of engagement in publicly funded treatment for OUD to compare total costs of crime during a hypothetical 6-month period following initiation of opioid agonist treatment (OAT) versus detoxification.

DESIGN

Retrospective, administrative data-based cohort study with comprehensive information on drug treatment and criminal justice systems interactions.

SETTING

Publicly funded drug treatment facilities in California, USA (2006-10).

PARTICIPANTS

A total of 31 659 individuals admitted for the first time to treatment for OUD, and who were linked with criminal justice and mortality data, were followed during a median 2.3 years. Median age at first treatment admission was 32, 35.8% were women and 37.1% primarily used prescription opioids.

MEASUREMENTS

Daily costs of crime (US$2014) were calculated from a societal perspective and were composed of the costs of policing, court, corrections and criminal victimization. We estimated the average marginal effect of treatment engagement in OAT or detoxification adjusting for potential fixed and time-varying confounders, including drug use and criminal justice system involvement prior to treatment initiation.

FINDINGS

Daily costs of crime during treatment compared with after treatment were $126 lower for OAT [95% confidence interval (CI) = $116, $136] and $144 lower for detoxification (95% CI = $135, $154). Summing the costs of crime during and after treatment over a hypothetical 6-month period using the observed median durations of OAT (161 days) and detoxification (19 days), we estimated that enrolling an individual in OAT as opposed to detoxification would save $17 550 ($16 840, $18 383).

CONCLUSIONS

In publicly funded drug treatment facilities in California, USA, engagement in treatment for opioid use disorders is associated with lower costs of crime in the 6 months following initiation of treatment, and the economic benefits were far greater for individuals receiving time-unlimited treatment.

Substance use disorder patient privacy and comprehensive care in integrated health care settings

The Affordable Care Act (ACA) expands health insurance coverage for substance use disorder (SUD) treatment, underscoring the value of improving SUD service integration in primarily physical health care settings. It is not yet known to what degree specialized privacy regulations-Code of Federal Regulations Title 42, Part 2 (42 CFR Part 2), in particular-will affect access to or the utilization and delivery of SUD treatment in primary care. In addition to exploring the emerging benefits and barriers that specialized confidentiality regulations pose to treatment in early adopting integrated health care settings, this article introduces and explicates 42 CFR Part 2 to support provider and administrator implementation of SUD privacy regulations in integrated settings. The authors also argue that, although intended to protect patients with SUD, special SUD information protection may inadvertently reinforce stigma against patients by purporting the belief that SUD is different from other health problems and must be kept private. In turn, this stigma may inhibit the delivery of comprehensive integrated care.

Gender differences in mortality among treated opioid dependent patients

AIMS

To assess gender differences in characteristics, mortality rates, and the causes and predictors of death among treated opioid-dependent individuals.

METHODS

Linked vital statistics data were obtained for all individuals first enrolled in publicly funded pharmacological treatment for opioid dependence in California from 2006 to 2010. Standardized mortality ratios (SMR) were calculated by gender. Cox proportional hazards models with time-varying covariates were fitted to determine the effect of gender on the hazard of all-cause mortality, controlling for covariates.

RESULTS

Over a median 2.6 years (interquartile range: 1.4-3.7), 1.031 deaths were observed, including 2.2% (259/11,564) of women and 3.7% (772/20,758) of men. Women had a greater increased risk of mortality compared to the general population (SMR 5.1 95% CI: 4.5, 5.7) than men (SMR 4.3 95% CI: 4.0, 4.6). The relative risk of death for women compared with men was 1.18 (95% CI: 1.02, 1.36). Women had a lower instantaneous hazard of all-cause mortality than men (HR 0.58, 95% CI 0.50, 0.68), controlling for other factors. Significant interaction effects indicated that among men, mortality risk was decreased by full-time employment and increased by non-daily heroin use (relative to daily use) and medical problems. Concurrent opioid and methamphetamine/cocaine use increased mortality risk among women and decreased it among men.

CONCLUSIONS

Treatment for opioid dependence is likely to reduce mortality risk among men by addressing employment and medical problems, and via interventions to reduce overdose risk after heroin abstinence, and among women by attending to the concurrent use of methamphetamine/cocaine and opioids.

Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006-10

AIMS

To estimate mortality rates among treated opioid-dependent individuals by cause and in relation to the general population, and to estimate the instantaneous effects of opioid detoxification and maintenance treatment (MMT) on the hazard of all-cause and cause-specific mortality.

DESIGN

Population-based treatment cohort study.

SETTING

Linked mortality data on all individuals first enrolled in publicly funded pharmacological treatment for opioid dependence in California, USA from 2006 to 2010.

PARTICIPANTS

A total of 32 322 individuals, among whom there were 1031 deaths (3.2%) over a median follow-up of 2.6 years (interquartile range = 1.4-3.7).

MEASUREMENTS

The primary outcome was mortality, indicated by time to death, crude mortality rates (CMR) and standardized mortality ratios (SMR).

FINDINGS

Individuals being treated for opioid dependence had a more than fourfold increase of mortality risk compared with the general population [SMR = 4.5, 95% confidence interval (CI) = 4.2, 4.8]. Mortality risk was higher (1) when individuals were out-of-treatment (SMR = 6.1, 95% CI = 5.7, 6.5) than in-treatment (SMR = 1.8, 95% CI = 1.6, 2.1) and (2) during detoxification (SMR = 2.4, 95% CI = 1.5, 3.8) than during MMT (SMR = 1.8, 95% CI = 1.5, 2.1), especially in the 2 weeks post-treatment entry (SMR = 5.5, 95% CI = 2.7, 9.8 versus SMR = 2.5, 95% CI = 1.7, 4.9). Detoxification and MMT both independently reduced the instantaneous hazard of all-cause and drug-related mortality. MMT preceded by detoxification was associated with lower all-cause and other cause-specific mortality than MMT alone.

CONCLUSIONS

In people with opiate dependence, detoxification and methadone maintenance treatment both independently reduce the instantaneous hazard of all-cause and drug-related mortality.

Utilization and outcomes of detoxification and maintenance treatment for opioid dependence in publicly-funded facilities in California, USA: 1991-2012

BACKGROUND

California treats the largest population of opioid dependent individuals in the USA and is among a small group of states that applies regulations for opioid treatment that are more stringent than existing federal regulations. We aim to characterize changes in patient characteristics and treatment utilization over time, and identify determinants of successful completion of detoxification and MMT retention in repeated attempts.

METHODS

State-wide administrative data was obtained from California Outcome Measurement System during the period: January 1st, 1991-March 31st, 2012. Short-term detoxification treatment and long-term maintenance treatment, primarily with methadone, was available to study participants. Mixed effects regression models were used to define determinants of successful completion of the detoxification treatment protocol (as classified by treatment staff) and duration of maintenance treatment.

RESULTS

The study sample consisted of 237,709 unique individuals and 885,971 treatment episodes; 837% were detoxification treatment episodes in 1994, dropping to 40.5% in 2010. Among individuals accessing only detoxification, the adjusted odds of success declined with each successive attempt (vs. 1st attempt: 2nd: OR: 0.679; 95% CI (0.610, 0.755); 3rd: 0.557 (0.484, 0.641); 4th: 0.526 (0.445, 0.622); 5th: 0.407 (0.334, 0.497); ≥6th: 0.339 (0.288, 0.399). For those ever accessing maintenance treatment, later subsequent attempts were longer in duration, and those with two or more prior attempts at detoxification had marginally longer subsequent maintenance episodes (hazard ratio: 0.97; 95% CI: 0.95, 0.99). Finally, only 10.9% of all detoxification episodes were followed by admission into maintenance treatment within 14 days.

CONCLUSIONS

This study has revealed high rates of detoxification treatment for opioid dependence in California throughout the study period, and decreasing odds of success in repeated attempts at detoxification.

Comparative Effectiveness of California's Proposition 36 and Drug Court Programs Before and After Propensity Score Matching

California's voter-initiated Proposition 36 (Prop 36) program is often unfavorably compared to drug courts, but little is empirically known about the comparative effectiveness of the two approaches. Using statewide administrative data, analyses were conducted on all Prop 36 and drug court offenders with official records of arrest and drug treatment. Propensity score matching was used to create equivalent groups, enabling comparisons of success at treatment discharge, recidivism over 12 months post-treatment entry, and magnitude of behavioral changes. Significant behavioral improvements occurred for both Prop 36 and drug court offenders, but while more Prop 36 offenders were successful at discharge, more recidivated over 12 months. Core programmatic differences likely contributed to differences in outcomes. Policy implications are discussed.

Integration of substance use disorder services with primary care: health center surveys and qualitative interviews

Background

Each year, nearly 20 million Americans with alcohol or illicit drug dependence do not receive treatment. The Affordable Care Act and parity laws are expected to result in increased access to treatment through integration of substance use disorder (SUD) services with primary care. However, relatively little research exists on the integration of SUD services into primary care settings. Our goal was to assess SUD service integration in California primary care settings and to identify the practice and policy facilitators and barriers encountered by providers who have attempted to integrate these services.

Methods

Primary survey and qualitative interview data were collected from the population of federally qualified health centers (FQHCs) in five California counties known to be engaged in SUD integration efforts was surveyed. From among the organizations that responded to the survey (78% response rate), four were purposively sampled based on their level of integration. Interviews were conducted with management, staff, and patients (n = 18) from these organizations to collect further qualitative information on the barriers and facilitators of integration.

Results

Compared to mental health services, there was a trend for SUD services to be less integrated with primary care, and SUD services were rated significantly less effective. The perceived difference in effectiveness appeared to be due to provider training. Policy suggestions included expanding the SUD workforce that can bill Medicaid, allowing same-day billing of two services, facilitating easier reimbursement for medications, developing the workforce, and increasing community SUD specialty care capacity.

Conclusions

Efforts to integrate SUD services with primary care face significant barriers, many of which arise at the policy level and are addressable.

Offender diversion into substance use disorder treatment: the economic impact of California's proposition 36

OBJECTIVES

We determined the costs and savings attributable to the California Substance Abuse and Crime Prevention Act (SACPA), which mandated probation or continued parole with substance abuse treatment in lieu of incarceration for adult offenders convicted of nonviolent drug offenses and probation and parole violators.

METHODS

We used individually linked, population-level administrative data to define intervention and control cohorts of offenders meeting SACPA eligibility criteria. Using multivariate difference-in-differences analysis, we estimated the effect of SACPA implementation on the total and domain-specific costs to state and county governments, controlling for fixed individual and county characteristics and changes in crime at the county level.

RESULTS

The additional costs of treatment were more than offset by savings in other domains, primarily in the costs of incarceration. We estimated the statewide policy effect as an adjusted savings of $2317 (95% confidence interval = $1905, $2730) per offender over a 30-month postconviction period. SACPA implementation resulted in greater incremental cost savings for Blacks and Hispanics, who had markedly higher rates of conviction and incarceration.

CONCLUSIONS

The monetary benefits to government exceeded the additional costs of SACPA implementation and provision of treatment.

Patterns of treatment utilization and methamphetamine use during first 10 years after methamphetamine initiation

The study examined joint trajectories of methamphetamine (MA) use and substance abuse treatment utilization and identified differences among pattern groups for a sample of 348 treated for MA use. Results from group-based trajectory modeling showed that treatment utilization during the first 10 years after initiation of MA use could be categorized into three distinctive patterns: about half the MA users have a pattern of low treatment utilization; one-fourth follow a quicker-to-treatment trajectory with higher probability of treatment during the first 5 years of MA use and less treatment in the next 5 years; and one-fourth have a slower-to-treatment trajectory with more treatment during the second half of the 10-year period. Four MA use patterns were identified: consistently low use, moderate, and high use, as well as a decreasing use pattern. Periods of greater likelihood of treatment participation were associated with periods of decreasing or lower frequency of MA use.

Development and initial feasibility of an organizational measure of behavioral health integration in medical care settings

In the advent of health care reform, models are sought to integrate behavioral health and routine medical care services. Historically, the behavioral health specialty has not itself been integrated, but instead bifurcated by substance use and mental health across treatment systems, care providers and even research. With the present opportunity to transform the health care delivery system, it is incumbent upon policymakers, researchers and clinicians to avoid repeating this historical error, and provide integrated behavioral health services in medical contexts. An organizational measure designed to assess this capacity is described: the Dual Diagnosis Capability in Health Care Settings (DDCHCS). The DDCHCS was used to assess a sample of federally-qualified health centers (N=13) on the degree of behavioral health integration. The measure was found to be feasible and sensitive to detecting variation in integrated behavioral health services capacity. Three of the 13 agencies were dual diagnosis capable, with significant variation in DDCHCS dimensions measuring staffing, treatment practices and program milieu. In general, mental health services were more integrated than substance use. Future research should consider a revised version of the measure, a larger and more representative sample, and linking organizational capacity with patient outcomes.

Integrating substance use disorder services with primary care: the experience in California

Integrating substance use disorder (SUD) services with primary care (PC) can improve access to SUD services for the 20.9 million Americans who need SUD treatment but do not receive it, and help prevent the onset of SUDs among the 68 million Americans who use psychoactive substances in a risky manner. We lay out the reasons for integrating SUD and PC services and then explore the models used and the experiences of providers as they have begun SUD/PC integration in California.

Do cultural and linguistic competence matter in Latinos' completion of mandated substance abuse treatment?

BACKGROUND

Increasing evidence suggests that culturally and linguistically responsive programs may improve substance abuse treatment outcomes among Latinos. However, little is known about whether individual practices or culturally and linguistically responsive contexts support efforts by first-time Latino clients to successfully complete mandated treatment.

METHODS

We analyzed client and program data from publicly funded treatment programs contracted through the criminal justice system in California. A sample of 5,150 first-time Latino clients nested within 48 treatment programs was analyzed using multilevel logistic regressions.

RESULTS

Outpatient treatment, homelessness, and a high frequency of drug use at intake were associated with decreased odds of treatment completion among Latinos. Programs that routinely offered a culturally and linguistically responsive practice-namely, Spanish-language translation-were associated with increased odds of completion of mandated treatment.

CONCLUSIONS

These preliminary findings suggest that concrete practices such as offering Spanish translation improve treatment adherence within a population that is at high risk of treatment dropout.

Differential outcomes of court-supervised substance abuse treatment among California parolees and probationers

To explore the effectiveness of court-supervised drug treatment for California parolees, offender characteristics, treatment experiences, and outcomes were examined and contrasted to those of probationers. The analysis used statewide administrative data on 4,507 parolees and 22,701 probationers referred to treatment by Proposition 36 during fiscal year 2006-2007. Compared with probationers, parolee problems were more severe at treatment entry, more were treated in residential settings, treatment retention was shorter, and fewer completed treatment. Regarding outcomes, fewer parolees were successful at treatment discharge and more recidivated over 12-months post admission. Both groups improved in many areas by treatment discharge, but improvements were generally smaller among parolees. Significant interaction effects indicated that parolees benefited from residential care and more treatment days, even after controlling for covariates. Court-supervised drug treatment for parolees can "work;" however, parolees have more frequent and diverse needs, and their outcomes are enhanced by more intensive treatment. Findings suggest methods for optimizing the effectiveness of criminal-justice-supervised programs for treating drug-dependent offenders.

Treatment outcomes for methamphetamine users: California Proposition 36 and comparison clients

Methamphetamine (meth) is a major drug of abuse in California and several other states, particularly among criminal offender populations. Over the past decade, substance abuse treatment systems have had to adapt to and accommodate the increasing needs of meth users and, in California, deal with the impact of Proposition 36, which has resulted in a greater number of criminal offenders entering the treatment system. This study examines selected treatment performance and outcome indicators for California Proposition 36 offenders entering substance abuse treatment for meth use and compares their performance and outcomes to other subgroups of California treatment clients differentiated by whether or not they were admitted to treatment through Proposition 36 and whether or not their primary substance was meth. Significant improvements in all outcome domains were seen across the populations, and treatment performance and outcomes were not substantively inferior for the offender or meth-using groups.

Treating opioid use under California's Proposition 36: differential outcomes by treatment modality

In California, Proposition 36 (Prop. 36) has led to positive outcomes for a significant proportion of participants-increases in drug treatment completion, reduced drug use and recidivism, and increased employment. However, there are notable differences in outcomes among Prop. 36 subgroups, with some of the poorest outcomes observed among opioid users. This may be because very few Prop. 36 opioid users were placed in narcotic treatment programs (NTPs). Prop. 36 opioid users who were placed in NTPs using methadone had the greatest reductions in opioid use from treatment intake to discharge, as compared to Prop. 36 opioid users who received outpatient drug-free or residential treatment. As such, NTPs should be considered to be a highly efficacious and viable treatment option for Prop. 36 opioid users. Thus, to improve treatment outcomes among Prop. 36 opioid users, it is essential that the provision and utilization of NTPs be enhanced.

Editors' introduction: Identifying and assessing promising practices for criminal justice clients--California Substance Abuse Research Consortium (SARC) meetings, 2010

Although some practices clearly have stronger supporting evidence than others, a single authoritative list of evidence-based practices (EBPs) that can be applied in the treatment of criminal justice clients does not exist. Nationally, use of EBPs is low, and such practices are generally only implemented under certain circumstances. To clarify these issues, experts from around the nation were invited to California for two research-to-policy meetings focused on EBP identification and implementation. Their presentations and the resulting series of articles in this special theme issue describe the current state of EBP research for criminal justice clients. To advance the field beyond the compilation of EBP lists, which can only represent a partial solution at best, next steps should include a greater focus on quality of implementation, intensity of quality assurance and monitoring, and training for underlying skills and principles.

Pathways to treatment retention for individuals legally coerced to substance use treatment: the interaction of hope and treatment motivation

BACKGROUND

Although several states have adopted policies diverting individuals convicted of non-violent drug offenses to substance use treatment, in lieu of incarceration or as a condition of probation, previous research has produced inconsistent findings on the effectiveness of such programs when comparing outcomes for legally coerced individuals to more voluntary entrants. Less studied in these populations is within group variation in treatment expectations and motivation influences, which have been shown to affect retention as well.

METHODS

As motivation has traditionally been viewed as contributing to treatment retention and higher levels of hope (the perception that goals can be met) are viewed as an asset in treatment, the role of these factors in predicting better retention between legally coerced and more voluntary clients were examined in a sample of 289 treatment admissions in California.

RESULTS

Results found that motivation mediates the relationship between hope and retention for participants in general. Although the differences in mediation between the legally coerced and the non-legally coerced were not significant, when examining the groups separately, there was a significant mediation of the relationship between hope and retention by motivation only for those individuals who were not legally coerced into treatment (p<.05).

CONCLUSION

The findings imply that while being legally coerced may lead to different pathways to treatment retention, for individuals who were not legally coerced, higher levels of hope may play an important role in determining treatment retention.

Evaluation of the Substance Abuse and Crime Prevention Act: Client Characteristics, Treatment Completion and Re-Offending Three Years After Implementation

Representing a major shift in criminal justice policy, Proposition 36 became law in November 2000 as the Substance Abuse and Crime Prevention Act (SACPA), permitting eligible offenders to receive probation with drug treatment instead of probation or incarceration. UCLA's Integrated Substance Abuse Programs was chosen by the California Department of Alcohol and Drug Programs to conduct an independent evaluation of SACPA. Analysis of the first three years of data provides information on the flow of offenders through SACPA, client and program characteristics, treatment completion rates, and effects on re-offending. Results show that most eligible offenders chose to participate in SACPA; almost two-thirds of these went on to enter treatment. Compared to other treatment clients, SACPA treatment clients included fewer women, were predominately between 26 and 45 years old, were more likely to use methamphetamine, and had been using drugs a longer. Most SACPA clients were referred to outpatient drug-free treatment regardless of primary drug problem, and about one-third completed treatment. Re-offending was lowest among SACPA offenders who completed treatment. Felony and misdemeanor drug arrests were higher among SACPA-era drug offenders than in a similar group of pre-SACPA drug offenders. Future reports will cover possible SACPA cost savings, additional clients outcomes, and overall lessons learned.

Promising practices for delivery of court-supervised substance abuse treatment: perspectives from six high-performing California counties operating Proposition 36

Operative for nearly a decade, California's voter-initiated Proposition 36 program offers many offenders community-based substance abuse treatment in lieu of likely incarceration. Research has documented program successes and plans for replication have proliferated, yet very little is known about how the Proposition 36 program works or practices for achieving optimal program outcomes. In this article, we identify policies and practices that key stakeholders perceive to be most responsible for the successful delivery of court-supervised substance abuse treatment to offenders under Proposition 36. Data was collected via focus groups conducted with 59 county stakeholders in six high-performing counties during 2009. Discussion was informed by seven empirical indicators of program performance and outcomes and was focused on identifying and describing elements contributing to success. Program success was primarily attributed to four strategies, those that: (1) fostered program engagement, monitored participant progress, and sustained cooperation among participants; (2) cultivated buy-in among key stakeholders; (3) capitalized on the role of the court and the judge; and (4) created a setting which promoted a high-quality treatment system, utilization of existing resources, and broad financial and political support for the program. Goals and practices for implementing each strategy are discussed. Findings provide a "promising practices" resource for Proposition 36 program evaluation and improvement and inform the design and study of other similar types of collaborative justice treatment efforts.

Stakeholder Consensus and Circumvention in Drug Diversion Programs: Findings from California's Substance Abuse and Crime Prevention Act (Proposition 36)

Nearly 50,000 drug offenders are annually offered treatment in lieu of traditional sentencing as a result of California's voter-approved Substance Abuse and Crime Prevention Act (SACPA). The challenges SACPA currently faces and their potential solutions may be similar to those faced by diversion programs in other regions. Stakeholders responsible for SACPA implementation were surveyed about the impact of recent budget cuts and were asked for suggestions on how to improve SACPA. Budget cuts undermined portions of the law that stakeholders agreed with and stakeholders themselves sought to circumvent portions of the law that they disagreed with. However, two areas of broad stakeholder agreement emerged: 1) funding should be increased, and 2) the option of brief jail sanctions for noncompliant participants should be made available. To address current challenges, key stakeholder groups should collectively draft and propose a revised version of the law using these areas of agreement as a foundation.

Improving the accountability of California's public substance abuse treatment system through the implementation of performance models

Improving the care for individuals with substance use disorders is a national health policy priority. Like other parts of the health care system, the addiction field is under pressure for higher accountability-more efficient use of treatment resources, the delivery of quality services, and the production of positive client outcomes. This introductory article highlights the importance of the collection of articles being published in this special issue as they describe California's efforts toward making the alcohol and drug (AOD) treatment system more accountable and effective.

Criminal justice itreatment admissions for methamphetamine use in California: a focus on Proposition 36

Methamphetamine (MA) use is considered as one of the nation's most pressing drug problems. In California, MA use has outstripped all other drugs in epidemiological extent, law enforcement activities, and treatment services demand. An opportunity for further study of MA use and its treatment emerged from a change in offender sentencing options introduced by California's Substance Abuse and Crime Prevention Act of 2000 (SACPA). Results indicate that statewide admissions for MA rose from 8.4% in FY 1992/1993 to 34.6% in FY 2004/2005, a four-fold increase over the 13 years. From the year before SACPA implementation to the year after, the percentage of treatment admissions due to MA use increased from 18.8% to 25.6%, an increase largely due to the fact that SACPA admissions were over 50% MA users. With the exception of alcohol, MA users entering treatment through SACPA had higher completion rates (about one third) from community based treatment than users of other primary drugs. This result held true for demographic and other subgroups of MA users. Multivariate regression results illuminate the relative importance of the variables examined. Implication of the findings for policy, intervention services, and research are discussed.

Crossed categorization beyond the two-group model

Four studies examined processing of in-group and out-group information with stimuli that are more complex than those used in previous crossed categorization studies. A diverse set of predictions is generated by previous theoretical work to account for how participants will integrate information stemming from multiple group memberships. Heuristic, threshold-based processing of information was supported over algebraic processing. Participants appeared to divide stimuli into "in-grouplike" and "out-grouplike" metacategories. However, the threshold at which this distinction was made, and whether it was based on in-group favoritism or out-group derogation, was influenced by the nature of the situation and the task participants performed. Advantages of crossed categorization research that moves beyond the traditional two-group model are discussed.

The California Substance Abuse Research Consortium: origins, history, and issues

When research results are passively presented in the policy world, especially when policy is tied to politics, researchers are often surprised and disappointed that officials do not attend to the obvious applications of their work. Active, timely, bidirectional exchange of information among parties is crucial. However, many contextual influences inhibit exchange efforts and must be recognized and understood in order to be overcome. Obstacles include "political entropy," bureaucratic "deference to hierarchy," media distortions, failure to reimburse provider staff in-service training, and comfort by all with the "way things are." Countering these contextual negative influences requires at least two "champions" (one from the government agency involved and one from academia), persuasion via reason, use of contemporary, politically correct rhetoric, building support through the most important constituencies, and, finally, pluck, persistence, and the ability to adapt to the inevitably changing context. This article discusses each of these aspects and describes examples of problems and solutions that have occurred throughout the history of substance abuse research and information exchange within the context of one key California effort, first known as the State Epidemiology Work Group, and later as the Substance Abuse Research Consortium.

The effectiveness of drug abuse treatment: a meta-analysis of comparison group studies

A meta-analysis was conducted on 78 studies of drug treatment conducted between 1965 and 1996. Each study compared outcomes among clients who received drug treatment with outcomes among clients who received either minimal treatment or no treatment. Five methodological variables were significant predictors of effect size. Larger effect sizes were associated with studies with the following characteristics: smaller numbers of dependent variables, significant differences between groups at admission, low levels of attrition in the treatment group, a passive comparison group (no treatment, minimal treatment) as opposed to an active comparison group (standard treatment), and drug use determined by a drug test. Controlling for these methodological variables, further analyses indicated that drug abuse treatment has both a statistically significant and a clinically meaningful effect in reducing drug use and crime, and that these effects are unlikely to be due to publication bias. For substance abuse outcomes, larger effect sizes tended to be found in studies in which treatment implementation was rated high, the degree of theoretical development of the treatment was rated low, or researcher allegiance to the treatment was rated as favorable. For crime outcomes, only the average age of study participants was a significant predictor of effect size, with treatment reducing crime to a greater degree among studies with samples consisting of younger adults as opposed to older adults. Treatment modality and other variables were not related to effect sizes for either drug use or crime outcomes

Meta-analysis of HIV risk-reduction interventions within drug abuse treatment programs

A meta-analysis was conducted on studies using a treatment-comparison group design to evaluate HIV/AIDS risk-reduction interventions for clients enrolled in drug abuse treatment programs. Overall, the interventions studied were found to have a reliable positive (weighted) effect size (d = 0.31), and this was unlikely to be due to publication bias. Effect sizes for specific categories of outcome variables were 0.31 for knowledge, attitudes, and beliefs; 0.26 for sexual behavior; 0.62 for risk-reduction skills; and 0.04 for injection practices. A number of potential moderators were examined. Effect sizes were negatively correlated with the presence of predominantly ethnic minority samples and positively correlated with the number of intervention techniques used, the intensity of the intervention, intervention delivery at a later stage of drug treatment or within methadone treatment, and the presence of a number of specific intervention techniques.