State inequities: Gaps in planned treatment for criminal legal referrals with opioid use disorder across two decades of US treatment admissions.

BACKGROUND AND OBJECTIVES: Criminal-legal (CL) referrals to addiction treatment have historically had low utilization of medications for opioid use disorder (MOUD). While state differences have been reported, an in-depth longitudinal analysis of state-by-state differences is lacking. METHODS: The Substance Abuse and Mental Health Services Administration Treatment Episode Dataset-Admissions 2000-2020 provided data for individuals entering their initial treatment with an opioid as their primary substance. Outcome was planned use of MOUD, assessing odds ratio (OR) of CL referrals relative to non-CL referrals cumulatively over the 21-year period and as incremental change (change in relative disparity) using effect sizes, stratified by each state. RESULTS: 2,187,447 cases met the criteria. Planned MOUD occurred in 37.7% of non-CL clients versus 6.5% of CL clients (OR = 0.11, 95% confidence interval = 0.11-0.12). For all clients, planned MOUD increased from 2000 (33.9%) to 2020 (44.8%). This increase was blunted within CL clients, increasing from 2000 (6.4%) to 2020 (13.3%). Rhode Island saw the greatest improvements in equity. DISCUSSION AND CONCLUSIONS: While rates of planned MOUD increased over the 21 years, a significant disparity persisted among CL clients in most states. As opioid use disorders and opioid-related overdoses are more prevalent among those involved with the CL system, improving this has high impact. SCIENTIFIC SIGNIFICANCE: Provides the most comprehensive analysis of state-by-state inequities in MOUD access for CL relative to non-CL referrals over a 21-year period through use of a national data set. Positive outliers are used as case examples for others to follow in pursuit of more equitable care.

Perceived risk of LSD varies with age and race: evidence from 2019 United States cross-sectional data.

PURPOSE: Psychedelics are being explored for their potential therapeutic benefits across a wide range of psychiatric diagnoses and may usher in a new age in psychiatric treatment. There is stigma associated with these currently illegal substances, and use varies by race and age. We hypothesized that minoritized racial and ethnic populations, relative to White respondents, would perceive psychedelic use as riskier. METHODS: Using 2019 cross-sectional data from the National Survey of Drug Use and Health, we conducted a secondary analysis of 41,679 respondents. Perceived risk of heroin was used as a surrogate for overall risk of illegal substance use; heroin and lysergic acid diethylamide were the only substances queried this way in the sample. RESULTS: A majority regarded lysergic acid diethylamide (66.7%) and heroin (87.3%) as a great risk if used once or twice. There were clear differences by race, with White respondents and those indicating more than one race having significantly lower perceived risk of lysergic acid diethylamide than respondents from other groups. Perceived risk of use also significantly increased with age. CONCLUSION: Perceived risk of lysergic acid diethylamide is unevenly distributed across the population. Stigma and racial disparities in drug-related crimes likely contribute to this. As research into potential therapeutic indications for psychedelics continues, perceived risk of use may change.

Sex Differences in Recovery Capital Gains Post-Incarceration.

BACKGROUND: People with substance use disorders are highly prevalent in the carceral system. Recovery capital (RC) is the resources available to an individual to initiate or maintain substance use cessation. Sex differences have been identified in RC during both active substance use and recovery in the general population, however, less is known about these sex differences in the post-incarceration population. METHODS: Participants (n = 136) were those with an opioid or stimulant use disorder with past year involvement with the Iowa criminal justice system (USA), who completed the Assessment of Recovery Capital (ARC) twice over a six-month cohort study. Participants were involved in an addiction clinic that utilized active case management. Analysis of covariance evaluated changes in ARC during the study. Separate models compared total ARC and individual ARC domains, with sex as the independent variable of interest. Model means were generated for interpretation based on sex, comparing baseline and study endpoint ARC scores. RESULTS: There were no baseline sex differences in total ARC. ARC increased significantly for the group, however, males showed disproportionate growth. Females ended the study with a mean ARC of 37.8 (SD= 9.3) and males finished at 41.6 (SD= 9.3), which was a significant difference (p = 0.044); this significant difference was driven by ARC subdomains of 'Psychological Health' and 'Physical Health.' CONCLUSIONS: People post-incarceration are at high risk for return to substance use. Treatment that is informed by sex-based differences may have the potential to decrease the differing rates of growth in RC between sexes.

Older Adult Substance Use Treatment First-Time Admissions Between 2008 and 2018.

OBJECTIVES: To see whether the percentage of older adults entering substance use treatment for their first time continued to increase and whether there were changes in the use patterns leading to the treatment episode, particularly an increase in illicit drugs. DESIGN: Public administrative health record study. SETTING: The Treatment Episode Data Sets publicly available from the Substance Abuse Mental Health Services Administration from 2008 to 2018. PARTICIPANTS: Young adults age 30-54 years (N = 3,327,903) and older adults age 55 years and older (N = 453,598) with a first-time admission for a publicly funded substance use treatment. MEASUREMENTS: Demographic and substance use history variables at admission. RESULTS: The proportion of older adults going for substance use treatment for the first time continued to increase between 2008 and 2018 relative to younger adults, continuing the trend of increasing first-time admission between 1998 and 2008. For the first time, the primary substance at admission for older adults was an illicit substance only, surpassing alcohol only and the combination of alcohol and illicit drug use. In this period, use of opioids, particularly heroin, and methamphetamine increased among older adults entering treatment. CONCLUSIONS: As our population ages and substance use trends change, healthcare providers that take care of older adults must have skills to prevent, screen for, diagnose, and treat substance use disorders. Given recent trends in substance use and treatment among older adults, substance use treatment programs must adapt to meet the needs of an older population.

Mortality in Treatment-seeking Older Adults Receiving Medications for Opioid Use Disorder.

OBJECTIVES: Older adults (OAs; age 55+ years) are increasingly seeking specialty treatment of opioid use disorder. Previous analyses of the Treatment Episode Data Set-Discharges (TEDS-D) database have reported higher rates of in-treatment mortality for those receiving medications for opioid use disorder (MOUD). We evaluate current trends in mortality for treatment-seeking OAs. METHODS: Using the 2020 TEDS-D, logistic regression predicted in-treatment mortality for OAs from planned MOUD, service level, and interaction terms. RESULTS: Of the 26,993 OA treatment discharges, 679 people were discharged due to death (2.52%). OAs with MOUD (3.65%, 95% confidence interval [CI], 3.37%-3.95%) were significantly more likely to discharge due to death than those without MOUD (0.82%; 95% CI, 0.66%-1.01%). Most records were for nonintensive outpatient (83.7%; n = 22,588), which had the highest mortality (2.89%; 95% CI, 2.68%-3.11%); intensive services (n = 4405) had a mortality rate of 0.61% (95% CI, 0.42%-0.89%). Among OAs, planned MOUD with nonintensive outpatient services had a mortality rate of 4.17% (95% CI, 3.56%-4.9%). CONCLUSIONS: This TEDS-D analysis extends previous literature highlighting a significant interaction between planned MOUD and service intensity on in-treatment mortality for OAs. Additional research is needed to address the causal mechanisms behind these interactions and inform the delivery of safe effective care in the growing OA population.

Recovery Capital Correlates With Less Methamphetamine Use and Crime in the Community.

OBJECTIVES: Reentry postcorrectional involvement is a high-risk time for patients with a history of addiction. We investigated whether participation in an addiction medicine clinic with active case management led to improvements in patients' recovery capital and whether there were associated changes in criminal activity and co-occurring methamphetamine or alcohol use. METHODS: Participants (n = 136) were patients with an opioid or stimulant use disorder who had Department of Corrections involvement in the preceding year, who completed the Assessment of Recovery Capital (ARC) and reported criminal activity and days of methamphetamine or alcohol use twice over a 6-month study. Three logistic regression models were used to assess changes in total ARC with criminal activity, alcohol use, and methamphetamine use over the previous 30 days. RESULTS: Baseline mean (SD) ARC scores were 34.1 (11.1) and increased to a mean (SD) score of 40.3 (9.4) at study end. A 1-SD shift in ARC was significantly protective across outcomes, with adjusted odds ratios of 0.32, 0.18, and 0.34 for any past 30-day criminal activity, alcohol use, or methamphetamine use. There was no significant difference in baseline ARC, crimes committed, days of alcohol use, or days of methamphetamine use for study completers versus noncompleters; however, unmeasured confounders may have had a differential impact on retention. CONCLUSIONS: Recovery capital provides an additional framework to help address patients' substance use and criminal activity in a multifaceted way, which is especially important in the postincarceration community. Recovery capital is dynamic and has multiple areas to target psychosocial interventions.

Recovery Capital Gains May Precede Craving Reduction in Opioid Use Disorder.

Purpose: Cravings for drugs and alcohol have been significantly associated with worse treatment outcomes. We investigated if improvements in recovery capital (RC) (eg, a measure of social capital/network, financial resources, education, and cultural factors) over time were associated with decreased reported cravings. Patients and Methods: The original cohort consisted of 133 participants (63 females) with opioid use disorder seeking outpatient treatment, who completed the Assessment of Recovery Capital (ARC) (range 0 to 50) and the Brief Addiction Monitor (BAM) thrice over the 6-month study. Intervention was medication and case management. Analysis included one-way mixed models testing change over time for ARC total scores and single question craving rating (5-point Likert scale). Cross-lagged panel estimates used structural equation models with variables z-scored, allowing for path coefficient evaluation as standard deviations (sd). Results: Total ARC significantly increased over the study (χ2 = 33.77, df = 2, p < 0.0001), with baseline of 36.6 (n = 114, sd = 11.1) and 6-month of 41.2 (n = 107, sd = 9.5). Craving also changed significantly (χ2 = 8.51, df = 2, p < 0.015), with baseline of 1.1 (n = 101, sd = 1.2) and 6-month of 0.9 (n = 107, sd = 1.1). The cross-lag from baseline RC to 3-month craving was significant (ß = -0.28, SE = 0.11, z = -2.53, p < 0.011). The converse was not true; baseline craving did not affect later RC. Results were similarly significant when comparing 3-month to 6-month. The majority of sample was on buprenorphine. Conclusion: As RC improves, the reported cravings at both 3- and 6-month study time points are significantly reduced. When evaluated inversely, there was not a significant association with baseline cravings and follow-up RC. Significant path coefficients provide an estimation of a directional effect from increased RC towards craving reduction.

Evidence of telescoping in females across two decades of US treatment admissions for injection drug use: 2000-2020.

Background: People who inject drugs (PWID) have an increased risk of soft tissue infection, drug overdose and death. Females may be particularly vulnerable due to barriers to substance use disorder (SUD) treatment entry, stigma, and telescoping, or the greater severity in substance use-related comorbidity and consequences despite a shorter history of use. We set out to identify sex differences in United States injection drug use (IDU). Methods: The Treatment Episode Dataset-Admission (2000-2020) provided data to identify PWID undergoing their initial SUD treatment admission. Mann-Whitney U test, chi-square, and Spearman correlations were used for ordinal variables, categorical variables, and to assess similarity of male/female trends over the 21 years, respectively. The probabilistic index (PI) and Cramer's V provided effect sizes for Mann-Whitney U tests and chi-square tests, respectively. Results: A total of 13,612,978 records existed for cases entering their initial treatment. Mapping to a history of IDU left 1,458,695 (561,793 females). Females had a higher prevalence among PWID across all 21 years; IDU trends were essentially identical between males and females (r = 0.97). Females endorsed beginning their primary substance later in life (PI = 0.47, p < 0.0001) and entered treatment after a shorter period of substance use (PI = 0.57, p < 0.0001). Conclusions: We saw evidence of telescoping among PWID with a SUD entering their initial episode of treatment. Interventions should be implemented prior to the transition to IDU, and this window of opportunity is shortened in females. Utilizing gender-responsive treatment options may be a way to increase treatment-seeking earlier in the disease course.

Services Available at United States Addiction Treatment Facilities That Offer Medications versus Behavioral Treatment Only: A Cross-Sectional, Observational Analysis.

Purpose: Substance use disorders (SUDs) are widespread and cause significant morbidity and mortality, yet most people in the United States with a SUD do not receive treatment. Recommendations call for widespread use of pharmacotherapy, including medications for opioid use disorder (MOUD). However, many facilities do not offer a full array of medication treatments. This study aims to characterize programs that do and do not offer pharmacotherapy as part of addiction treatment services. We hypothesized that the availability of pharmacotherapy would predict the existence of other recommended components of treatment. Patients and Methods: We analyzed characteristics regarding treatment facilities (n = 15,782) recorded by the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) to determine how many SUD treatment facilities offer any pharmacotherapy. We compared facilities that offer any pharmacotherapy to facilities that offer none. Results: We found that 65% of SUD treatment facilities that responded to the N-SSATS survey provided at least one pharmacotherapy, while 35% of SUD treatment facilities did not. The facilities that provided at least one pharmacotherapy offered, on average, 6 additional treatment options (Cohen's d = 0.87; 95% CI: 0.84-0.91). Psychiatric medications were the most commonly available pharmacotherapy, followed by buprenorphine/naloxone and naltrexone. Conclusion: These results support that pharmacotherapy availability, such as MOUD, at SUD treatment facilities is associated with an increased number of recommended treatment components. Since MOUD has been shown elsewhere to reduce mortality for people with OUD, it should be universally available at SUD treatment facilities. Further efforts are needed to make pharmacotherapy more widely available.

Substance Use in Pregnancy: Identifying Stigma and Improving Care.

This review examines the impact of stigma on pregnant people who use substances. Stigma towards people who use drugs is pervasive and negatively impacts the care of substance-using people by characterizing addiction as a weakness and fostering beliefs that undermine the personal resources needed to access treatment and recover from addiction, including self-efficacy, help seeking and belief that they deserve care. Stigma acts on multiple levels by blaming people for having a problem and then making it difficult for them to get help, but in spite of this, most pregnant people who use substances reduce or stop using when they learn they are pregnant. Language, beliefs about gender roles, and attitudes regarding fitness for parenting are social factors that can express and perpetuate stigma while facilitating punitive rather than therapeutic approaches. Because of stigmatizing attitudes that a person who uses substances is unfit to parent, pregnant people who use substances are at heightened risk of being screened for substance use, referred to child welfare services, and having their parental rights taken away; these outcomes are even more likely for people of color. Various treatment options can successfully support recovery in substance-using pregnant populations, but treatment is underutilized in all populations including pregnant people, and more knowledge is needed on how to sustain engagement in treatment and recovery activities. To combat stigma when working with substance-using pregnant people throughout the peripartum period, caregivers should utilize a trauma-informed approach that incorporates harm reduction and motivational interviewing with a focus on building trust, enhancing self-efficacy, and strengthening the personal skills and resources needed to optimize health of the parent-baby dyad.