Disparities in Latino substance use,service use,and treatment: Implications for culturally and evidence-based interventions under health care reform

Background

The goal of this systematic literature review was to enhance understanding of substance use, service use, and treatment among Latino subgroups to improve access to care and treatment outcomes in an era of health care reform.

Methods

The authors used 13 electronic databases and manually searched the literature from January 1, 1978, to May 30, 2013. One hundred (69%) of 145 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus discussions and a content expert reconciled discrepancies.

Results

Current rates of alcohol and substance abuse among Latinos are comparable to or surpass other U.S. ethnic groups. Disparities in access and quality of care are evident between Latinos and other ethnic groups. As a heterogeneous group, Latinos vary by geographic region in terms of substance of choice and their cultural identity takes precedence over general ethnic identity as a likely determinant of substance abuse behaviors. There is growing research interest in systems influencing treatment access and adherence among racial/ethnic and gender minority groups. However, studies on Latinos’ service use and immediate treatment outcomes have been both limited in number and inconsistent in findings.

Conclusions

This review identified human capital, quality of care, and access to culturally responsive care as key strategies to eliminate disparities in health and treatment quality. Implications are discussed, including the need for effectiveness studies on Latinos served by systems of care that, under health care reform, are seeking to maximize resources, improve outcomes, and reduce variation in quality of care.     

Substance use(r) treatment and health disparities: some considerations or an askance look at institutionalized substance use(r) intervention disparities

It is necessary to consider substance user treatment and derived health disparities in terms of: historical perspectives, stereotyping and "homogenization"; mystification; institutionalized disinformation; institutional myopia; institutionally created and maintained paradoxes; organizational, systemic, and human failure; the status of facts; environmental considerations; conceptual masking and overloading; fictions and fantasies; policy models and policy perversion; resource ignorance; slogans; de facto realities; the phenomenon of "lifeless lucidity" when statistical significance is not matched by substantive significance, problem definitions, and current unresolved critical issues that merit attention. The article's central thesis is that substance user treatment failure and derived health disparities are built into this complex, chaotic, nonlinear, multidimensional, highly politicalized, arbitrary, but institutionalized and "ghettoized" field that is also faulted by human, systemic, and organizational errors and that is removed from the "normed," mainstream of intervention and innovation.     

Comparing barriers to mental health treatment and substance use disorder treatment among individuals with comorbid major depression and substance use disorders

Barriers to both mental health and substance use disorder treatments have rarely been examined among individuals with comorbid mental health and substance use disorders. In a sample of 393 adults with 12-month major depressive episodes and substance use disorders, we compared perceived barriers to these two types of treatments. Data were drawn from the 2005–2011 US National Surveys on Drug Use and Health. Overall, the same individuals experienced different barriers to mental health treatment versus substance use disorder treatment. Concerns about negative views of the community, effects on job, and inconvenience of services were more commonly reported as reasons for not receiving substance use disorder treatment. Not affording the cost of care was the most common barrier to both types of treatments, but more commonly reported as a barrier to mental health treatment. Improved financial access through the Affordable Care Act and parity legislation and integration of mental health and substance use disorder services may help to reduce treatment barriers among individuals with comorbid mental health and substance disorders.     

Implications of genetic epidemiology for the prevention of substance use disorders

Despite advances in characterizing human genotypes, the complex process through which genes exert their influence limits the application of molecular genetics to human diseases. Substance use disorders are necessarily complicated by gene-environment interaction because exposure to an exogenous substance is required for their development. The methods of genetic epidemiology are specifically designed to identify sources of complexity that impede etiologic findings and prevention efforts. The goal of this paper is to illustrate the application of family study methods to identify risk factors for substance abuse and their implications for prevention. The Yale Family Study is a controlled family study of the comorbidity of substance and psychiatric disorders. The sample consists of 223 probands with substance use and/or an anxiety disorders and community controls, 1218 adult first degree relatives and spouses, and 203 offspring (ages 7-17) followed for 8 years. Results indicated familial aggregation of substance disorders in adults and children, independence of familial aggregation of alcoholism and drug dependence, and specificity of familial clustering of some drugs of abuse. Familial factors are more strongly associated with substance dependence than abuse, with an attributable risk of 55%. Premorbid psychiatric disorders--social phobia and bipolar affective disorder in adults, and depression, anxiety, conduct, and oppositional defiant disorders in children--were strongly associated with the subsequent development of substance dependence (attributable risks ranging from 44 to 86%). A family history of substance abuse and premorbid psychopathology are strongly associated with the development of substance use disorders. Implications for primary and secondary prevention are discussed. As specific genetic vulnerability markers for substance use disorders become identified, application of the tools of genetic epidemiology may be employed to identify specific environmental risk factors that may serve as targets for prevention.     

Controlling and policing substance use(rs)

Controlling drug use--a dynamic, global, politicalized process--is reviewed in terms of selected types of drugs, "natural levels" of drug demand and use, drug markets and the drug market environment, types of traffickers, illicit drug trade profits, approaches to drug control ("War on Drugs", "Zero Tolerance" programs and policies, "normalizing" and legalizing selected drugs), including UN's then relatively recent "Balanced Approach" and facets of drug law enforcement (drug prices and purity levels and values of drug seizures), including various rarely noted benefits to intervention programs and control agents. Unresolved issues and needed "tools" are noted while considering the implications of the first UN's World Drug Report data.     

Implementing integrated treatment for co-existing substance use and severe mental health problems in assertive outreach teams: training issues

This study sought to evaluate systematically training and implementation of a specific integrated treatment approach for co-occurring problem substance use and mental health within existing assertive outreach (AO) teams. The AO team was treated as a whole unit rather than as individual clinicians. They were provided with training and supervision to deliver a cognitive - behavioural integrated treatment approach. In a quasi-experimental time-lag design three teams were trained immediately and two others after an 18-month delay. There was evidence that teams acquired confidence and skills relevant to working with combined problems and that these gains were maintained over time. These results were replicated in the two teams trained after the delay. This study suggests that training mental health staff to use an integrated treatment approach is well received and produces lasting changes in confidence and skills. However, there are a number of issues related to staff training, shifting attitudes and implementation of integrated approaches into routine mental health practice. These issues are considered and suggestions made for staff training. [Graham HL. Implementing integrated treatment for co-existing substance use and severe mental health problems in assertive outreach teams: training issues. Drug Alcohol Rev 2004;23:463-470]     

Cognitive behaviour therapy (CBT) for the treatment of co-occurring depression and substance use: current evidence and directions for future research

ISSUES AND APPROACH: The high rates of co-occurring depression and substance use, and the negative impact of this on illness course and outcomes have been well established. Despite this, few clinical trials have examined the efficacy of cognitive behaviour therapy (CBT). This paper systematically reviews these clinical trials, with an aim of providing recommendations for how future research can develop a more robust evidence base for the treatment of these common comorbidities. Leading electronic databases, including PubMed (ISI) and PsychINFO (CSA), were searched for peer-reviewed journal articles using CBT for the treatment of co-occurring depression and substance use. Of the 55 articles identified, 12 met inclusion criteria and were included in the review. KEY FINDINGS: There is only a limited evidence for the effectiveness of CBT either alone or in combination with antidepressant medication for the treatment of co-occurring depression and substance use. While there is support for the efficacy of CBT over no treatment control conditions, there is little evidence that CBT is more efficacious than other psychotherapies. There is, however, consistent evidence of improvements in both depression and substance use outcomes, regardless of the type of treatment provided and there is growing evidence that that the effects of CBT are durable and increase over time during follow up. CONCLUSIONS: Rather than declaring the 'dodo bird verdict' that CBT and all other psychotherapies are equally efficacious, it would be more beneficial to develop more potent forms of CBT by identifying variables that mediate treatment outcomes.     

Maximizing potential: federal financing for treatment of adolescents with substance use disorders

The federal government is making a significant contribution to the treatment of adolescents with substance use disorders. However, funds are scattered across a number of policy domains. While some federal policies are complementary, many overlap, illustrating not only the complexity of collaborative efforts on the part of the implementing federal agencies but also the diversity of partnerships supporting adolescent substance use treatment. Changes in the organization and financing of health care delivery, coupled with the complex interaction of federal policies that address this population, affect the efficiency and effectiveness of federal policy responses to the problem. Equally important are the gaps in federal policy and the inadequacy of federal programs to reach all youth in need. This article analyses existing federal policies and programs and concludes that a seamless, multidisciplinary system that transcends traditional federal policy boundaries must be designed and implemented.     

Integrated,exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout

High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.     

Experiential avoidance,distress tolerance,and substance use cravings among adults in residential treatment for substance use disorders

Substance use cravings are a known predictor of relapse to substance use following treatment for a substance use disorder. Thus, research on factors that may be correlated with cravings, and could then be targeted in substance use treatment, is needed. Both distress tolerance and experiential avoidance, similar but distinct constructs, are independently associated with substance use cravings. However, no known research has examined these constructs as simultaneous predictors of substance use cravings, which may have important implications for treatment. The current study examined this in a sample of men and women in residential substance use treatment (n = 117). The authors used pre-existing data from a larger study where men and women were recruited for participation from a residential substance use treatment facility. The majority of the sample was male (n = 87; 74.3%) and Caucasian (92.2%). The mean age was 41.27 (standard deviation = 10.68). Better distress tolerance and lower experiential avoidance were negatively and significantly associated with alcohol and drug cravings, but only experiential avoidance remained significantly and negatively associated with cravings when both predictors were examined simultaneously. The current findings provide preliminary support for the importance of decreasing experiential avoidance in substance use treatment, which may result in reduced substance use cravings.     

Measurement of mental health in substance use disorder outpatients

Few studies have examined mental health (MH) attributes of patients with substance use disorder (SUD). This study examines the internal consistency, concurrent validity, and comparative level of MH attributes (i.e., optimism, life attitudes, spirituality/religiousness, social support, positive mood, hope, and vitality) in patients with SUD compared with the instrument development group. The internal consistency of optimism, spirituality/religiousness, positive mood, hope, and vitality were similar in both groups. Some subscales of the social support and life attitude measures had lower internal consistency than was found for the original samples, although internal consistency of more global constructs were comparable. Patients with SUD had higher positive mood, spirituality/religiousness, and hope scores, whereas social support, life attitudes, and optimism scores were lower than in the original sample. Correlations between MH attributes and recent life problems of patients with SUD generally supported the concurrent validity of the MH measures.     

Mental health versus substance abuse treatment programs for dually diagnosed patients

The aim of this study was to assess the similarities and differences of patients with co-existing psychiatric and substance use disorders attending treatment in either a mental health setting or a substance abuse treatment setting. A total of 129 patients were assessed, including 65 individuals from the substance abuse treatment center and 64 individuals from the mental health program. Treatment records were reviewed for diagnoses and sociodemographic data. While the two groups were highly similar with regard to age and ethnicity, there were significant differences in psychiatric profile, with the substance abuse treatment group having less severe diagnoses and no patients with schizophrenia, while the mental health treatment group had a majority of patients with schizophrenia. Other differences in the two groups, such as marital and parental status, disability status, and medical problems appeared to be directly linked with the aforementioned diagnostic profile. These data suggest important differences in characteristics of patients with comorbid disorders that appear to be dependent on the type of treatment program they attend. For the most effective management, integrated treatment programs should be aware of these differences and tailor service provision accordingly.