Top Manager Effects on Buprenorphine Adoption in Outpatient Substance Abuse Treatment Programs

To examine the influence of top managers’ characteristics on the adoption of buprenorphine for opioid dependence among U.S. outpatient substance abuse treatment units, this investigation analyzed a cross-sectional national study of 547 such units in the 2004–2005 wave of the Drug Abuse Treatment System Survey. Administrators reported their demographics, training, and treatment orientation, as well as features of the unit and its pattern of use of buprenorphine. Nationally, 15.8% of programs offered any buprenorphine services. Greater adoption of buprenorphine correlated with directors’ younger age, longer tenure, male gender, and weaker endorsement of abstinence as the most important treatment goal. Availability of naltrexone and medical services also correlated positively with buprenorphine adoption. The authors conclude that leaders’ characteristics are related to the adoption of innovative practices in addiction treatment programs. Future work should examine whether leadership development for community addiction programs might speed up the diffusion of buprenorphine and other innovative, evidence-based practices.     

Role of state policies in the adoption of naltrexone for substance abuse treatment

OBJECTIVE: To examine state policies associated with adoption of a pharmaceutical agent-naltrexone-by substance abuse treatment facilities to treat alcohol-dependent clients. DATA SOURCES: Facility-level data from the 2003 National Survey of Substance Abuse Treatment Services, and state-level data on policy and environmental factors from publicly available sources. STUDY DESIGN: We use facility- and state-level data in a cross-sectional, multilevel model to analyze state-level policies that are associated with treatment facilities' naltrexone adoption. DATA COLLECTION/EXTRACTION METHODS: The analysis uses survey data. PRINCIPAL FINDINGS: State Medicaid policies supporting the use of generic drugs, reducing drug costs, and permitting managed care organizations to establish policies encouraging use of generics were associated with higher odds of naltrexone adoption (by up to 96 percent). State policies limiting access to pharmaceutical technologies through Medicaid preferred drug lists, restricting access to pharmacy networks, and imposing general limitations on use of Medicaid benefits for rehabilitation for substance abuse treatment were associated with reduced odds of naltrexone adoption. CONCLUSIONS: Policy levers that are available to state governments are associated with the adoption of pharmaceutical technologies such as naltrexone that could help meet widespread need for access to clinically proven and cost-effective treatments for substance abuse.     

The Implementation of Smoking Cessation Counseling in Substance Abuse Treatment

Research on the implementation of smoking cessation counseling within substance abuse treatment organizations is limited. This study examines associations among counselors’ implementation of therapy sessions dedicated to smoking cessation, organizational factors, and counselor-level variables. A two-level hierarchical linear model including organization- and counselor-level variables was estimated using survey data collected from 1,794 counselors working in 359 treatment organizations. Overall implementation of smoking cessation counseling was low. In the final model, implementation was positively associated with counselors’ knowledge of the Public Health Service’s clinical practice guideline, perceived managerial support, and belief that smoking cessation had a positive impact on recovery. Private versus public funding and presence of a formal smoking cessation program were organization-level variables which interacted with these counselor-level effects. These results highlight the importance of organizational contexts as well as counselors’ knowledge and attitudes for effective implementation of smoking cessation counseling in substance abuse treatment organizations.     

Substance Abuse Treatment Programs’ Data Management Capacity: an Exploratory Study

Despite treatment improvement and performance management imperatives, little research describes the data management capacity of substance abuse treatment programs, and useful metrics are not available to gauge capacity. This exploratory study evaluates clinical and administrative data management at eight substance abuse treatment programs in four US states to identify factors for developing an appropriate metric. Findings indicate that programs tend to manage data inefficiently and have few protocols guiding information management. Barriers to better data management included lack of integrated information technology (IT) systems; limited funding, time, and staff for developing and implementing IT-related changes; and divergent staff skills in and attitudes toward IT. This snapshot of substance abuse treatment programs’ data management capabilities suggests a need for a metric to examine data management capability in these settings. Infusion of expertise, training, and funding are needed to improve substance abuse treatment programs’ IT-related systems and data management processes.     

Where Is Buprenorphine Dispensed to Treat Opioid Use Disorders? The Role of Private Offices,Opioid Treatment Programs,and Substance Abuse Treatment Facilities in Urban and Rural Counties

Context

Opioid use disorders are a significant public health problem. In 2002, the FDA approved buprenorphine as an opioid use disorder treatment when prescribed by waivered physicians who were limited to treating 30 patients at a time. In 2006, federal legislation raised this number to 100 patients. Although federal legislators are considering increasing these limits further and expanding prescribing privileges to nonphysicians, little information is available regarding the impact of such changes on buprenorphine use. We therefore examined the impact of the 2006 legislation—as well as the association between urban and rural waivered physicians, opioid treatment programs, and substance abuse treatment facilities—on buprenorphine distributed per capita over the past decade.

Methods

Using 2004-2011 state-level data on buprenorphine dispensed and county-level data on the number of buprenorphine-waivered physicians and substance abuse treatment facilities using buprenorphine, we estimated a multivariate ordinary least squares regression model with state fixed effects of a state’s annual total buprenorphine dispensed per capita as a function of the state’s number of buprenorphine providers.

Findings

The amount of buprenorphine dispensed has been increasing at a greater rate than the number of buprenorphine providers. The number of physicians waivered to treat 100 patients with buprenorphine in both rural and urban settings was significantly associated with increased amounts of buprenorphine dispensed per capita. There was no significant association in the growth of buprenorphine distributed and the number of physicians with 30-patient waivers.

Conclusions

The greater amounts of buprenorphine dispensed are consistent with the potentially greater use of opioid agonists for opioid use disorder treatment, though they also make their misuse more likely. The changes after the 2006 legislation suggest that policies focused on increasing the number of patients that a single waivered physician could safely and effectively treat could be more effective in increasing buprenorphine use than would alternatives such as opening new substance abuse treatment facilities or raising the overall number of waivered physicians.     

Harlem service providers’ perceptions of the impact of municipal policies on their clients with substance use problems

Substance abuse is a significant health and social problem in many low-income urban communities. Finding appropriate help for drug users has been identified as a significant barrier to reducing the barm from drug abuse. This report presents findings from a survey of service providers in the Central and East Harlem communities, New York City, conducted in 2000 to identify policy obstacles that impeded clients’ attempts to overcome substance use and related problems. Policies can affect substance users by making access to drug treatment more difficult or by imposing unrealistic expectations on substance users for eligibility for benefit programs. Respondents to the survey were asked to rate 30 specific policies as harmful or helpful to their clients and to assess how the policies acted as barriers or facilitators to getting services and reducing drug use. Eleven policies in the areas of drug treatment, corrections, and Medicaid were rated as harmful to their clients by more than 50% of the respondents. We discuss the implications of these and other findings for drug users’ ability to seek and receive help for their problems.     

Outcomes for medicaid clients with substance abuse problems before and after managed care

Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be undertreated (with too short and/or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit status versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18–64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N=1751) or 1996–1997 (after managed care, N=14,813), who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit vs not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.     

Consumer Perceptions of Integrated Trauma-Informed Services Among Women with Co-Occurring Disorders

As part of a national, multi-site treatment outcome study, an instrument was designed to assess consumers’ perceptions of key services integrating trauma, mental health, and substance abuse issues, the Consumer Perceptions of Care (CPC). This study evaluates the psychometric properties of this instrument and analyzes consumers’ perceptions of the services they received. The results suggest that the measure has four factors: services integration, choice in services, trauma-informed assessment, and respect for cultural identity. These factors demonstrated adequate reliability, and the overall results suggested that the measure is a reliable, sensitive, and valid reflection of consumers’ perceptions of their services and their providers for diverse racial and ethnic groups. Women in the intervention programs perceived their services as more highly integrated for trauma, mental health, and substance use than women in the services as usual or comparison programs, supporting its utility as a measure of programs designed to provide integrated services.     

Latina Mother–Daughter Dyads: Relations Between Attachment and Sexual Behavior Under the Influence of Alcohol or Drugs

Associations among mother–daughter attachment, mother and daughter substance abuse, and daughter’s sexual behavior under the influence of drugs and alcohol were investigated among 158 adult U.S. Latina daughters. Latina daughters were sampled from four mother–daughter dyad types: substance abusing mother and daughter, substance abusing mother only, substance abusing daughter only, and non-substance-abusing mother and daughter. Substance abusing daughters with substance abusing mothers, and daughters who were less strongly attached to their mothers, reported more sex under the influence of drugs. Age, marital status, substance abuse, and mother’s substance abuse all influenced the daughter’s sex under the influence of alcohol. An unexpected positive association between attachment and sex under the influence of alcohol was found for daughters who were more closely attached to a substance abusing mother. Implications for future research, and HIV/AIDS and drug prevention and treatment programs for Latinas are discussed.     

Addressing Trauma in Mental Health and Substance Use Treatment

Individuals with histories of violence, abuse, and neglect from childhood onward make up the majority of clients served by public mental health and substance abuse service systems. The greater the trauma, the greater the risk for alcoholism and alcohol abuse, depression, illicit drug use, suicide attempts, and other negative outcomes. Clearly, we cannot begin to address the totality of an individual’s healthcare, or focus on promoting health and preventing disease, unless we address trauma. Trauma-informed care is now the expectation, not the exception, in behavioral health treatment systems.     

Oregon's transition to a managed care model for Medicaid-funded substance abuse treatment: steamrolling the glass menagerie

The approval of a Health Care Financing Administration (now called Centers for Medicare and Medicaid Services) 1115 Medicaid waiver in Oregon allowed the state to design and implement an expanded publicly funded health care system, the Oregon Health Plan (OHP). Integral to OHP is the administration of physical and behavioral health services, including outpatient substance abuse treatment, through contracted managed care organizations. The two overarching changes to the outpatient substance abuse treatment system were expanded Medicaid eligibility and new operating procedures for the outpatient substance abuse treatment system. The authors used grounded theory to examine the effects of this transition on the treatment system, with an emphasis on the experiences of treatment providers.     

Assessing Culturally Competent Chemical Dependence Treatment Services for Mexican Americans

Mexican Americans struggling with chemical dependence are greatly underserved. Barriers to treatment include language, lack of culturally relevant services, lack of trust in programs, uninviting environments, and limited use and linkage with cultural resources in the community. This project aimed to develop a tool for assessing and planning culturally competent/relevant chemical dependence treatment services for Mexican Americans. Focus groups were conducted with experts in Mexican-American culture and chemical dependence from six substance abuse programs serving adult and adolescent Mexican Americans and their families. Sixty-two statements were developed describing characteristics of culturally competent/relevant organizations. Concept mapping was used to produce a conceptual map displaying dimensions of culturally competent/relevant organizations and Cronbach’s alpha was calculated to assess the internal consistency of each dimension. Analysis resulted in seven reliable subscales: Spanish language (α = 0.84), counselor characteristics (α = 0.82), environment (α = 0.88), family (α = 0.84), linkage (α = 0.92), community (α = 0.86), and culture (α = 0.89). The resulting instrument based on these items and dimensions enable agencies to evaluate culturally competent/relevant services, set goals, and identify resources needed to implement desired services for both individual organizations and networks of regional services.     

Treatment Patterns Among Offenders with Mental Health Problems and Substance Use Problems

Research on treatment utilization among offenders with mental health problems and substance use problems, i.e. the ‘triply troubled’, is scarce. The aim was to contribute to the general knowledge about treatment patterns among the triply troubled. This register-based study explored treatment patterns during a 3-year follow-up among 157 Swedish offenders with substance use problems who had undergone forensic psychiatric assessment. There were three subgroups of treatment users: low treatment, planned substance abuse treatment and substance abuse emergency room visits, and planned psychiatric treatment. About 40% of the participants displayed a stable treatment pattern. Outcomes were less successful for those participants displaying a non-stable treatment pattern. Allocation of treatment resources should take into account the associations between treatment patterns and recidivism into criminality. Also, it should be valuable for clinicians to gather information on treatment history in order to meet various treatment needs.     

Organizational factors related to AIDS/HIV education in outpatient substance abuse treatment units

The association of HIV and AIDS with intravenous drug use is well documented. Given this, substance abuse treatment providers must figure prominently in any effective national response to HIV/AIDS. The strategies employed by human service managers to address AIDS may be important in explaining how substance abuse treatment units implement policies and programs concerning AIDS-related prevention services. This paper utilizes data from the National Drug Abuse Treatment System Survey to examine how strategic activities concerning AIDS/HIV undertaken by outpatient substance abuse treatment unit managers impacted the provision of preventive AIDS-related services to clients. Results of multiple regression analysis indicate collaboration with other human service organizations and environmental scanning activities are important variables in explaining variation among substance abuse treatment units in the provision of AIDS prevention education to clients. Based on these findings, implications for future research and policy concerning AIDS prevention within the context of substance abuse treatment are made.     

Privatizing public mental health and substance abuse services: issues, opportunities, and challenges

Much like the medical care system, delivery systems for mental health and substance abuse services are being transformed rapidly by managed care. Public sector systems are now facing challenges to transfer service delivery responsibilities to private managed behavioral health care organizations as a way of containing treatment costs and realizing operational efficiencies. These privatization efforts entail a range of quality management issues that are specific to mental health and substance abuse problems, treatments, and clients.     

The Effect of the PROSPER Partnership Model on Cultivating Local Stakeholder Knowledge of Evidence-Based Programs: A Five-Year Longitudinal Study of 28 Communities

A substantial challenge in improving public health is how to facilitate the local adoption of evidence-based interventions (EBIs). To do so, an important step is to build local stakeholders’ knowledge and decision-making skills regarding the adoption and implementation of EBIs. One EBI delivery system, called PROSPER (PROmoting School-community-university Partnerships to Enhance Resilience), has effectively mobilized community prevention efforts, implemented prevention programming with quality, and consequently decreased youth substance abuse. While these results are encouraging, another objective is to increase local stakeholder knowledge of best practices for adoption, implementation and evaluation of EBIs. Using a mixed methods approach, we assessed local stakeholder knowledge of these best practices over 5 years, in 28 intervention and control communities. Results indicated that the PROSPER partnership model led to significant increases in expert knowledge regarding the selection, implementation, and evaluation of evidence-based interventions. Findings illustrate the limited programming knowledge possessed by members of local prevention efforts, the difficulty of complete knowledge transfer, and highlight one method for cultivating that knowledge.     

An agenda to combat substance abuse

Despite their huge health toll, substance abuse disorders remain underappreciated and underfunded. Reasons include stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, fragmented and weak leadership, powerful tobacco and alcohol industries, underinvestment in research, and difficult patients. Positive signs include declining prevalence rates, successful counter-marketing campaigns, changing public attitudes, new scientific discoveries that could yield new treatments, and effective new organizations. Further progress will require better treatment, more research, better education of health professionals, more nongovernmental support, and stronger leadership. Policy changes regarding each of the three substance groups are indicated, as are reforms in the criminal justice and educational systems.     

Managed care and technical efficiency in outpatient substance abuse treatment units

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.     

Availability of Services for Women in Outpatient Substance Abuse Treatment: 1995–2000

Women entering substance abuse treatment have more severe substance abuse problems and more medical and psychiatric comorbidities than men. Research shows that specialized women's services are associated with better retention and outcomes but relatively little is known about their availability nationwide. This study examined the adoption and implementation of reproductive and female-sensitive social services in a national sample of outpatient substance abuse treatment (OSAT) organizations in 1995 (N = 617) and 2000 (N = 571) by several organizational factors. Overall, reproductive and social services for women have not been widely adopted, although some services did increase over the study period, particularly social services. There was no evidence of large-scale decreases in service availability over the study period, although child care did decline. Nonprofit and public ownership (relative to for-profit) were associated with greater service provision. Managed care units had greater service adoption compared to nonmanaged care units, and this increased over time. Public units and hospital-affiliated units had greater service implementation than other units. However, OSAT units did not always implement the services they adopted, suggesting access to some services may be restricted.     

Organizational systems to support publicly funded tobacco treatment services

BACKGROUND: Professional societies and government organizations have promoted guidelines and best practices that encourage clinicians to routinely integrate cessation counseling into patient encounters. While research in health maintenance organizations has demonstrated that the development and maintenance of office systems do enable clinicians' smoking-cessation services, little is known about the adoption of system strategies in diverse organizations serving disadvantaged populations. METHODS: Data were collected via face-to-face interviews from November 2001 to October 2002 using a standardized systems assessment checklist at service delivery sites of 83 funded community health service agencies, which included hospitals, community health centers, and other organizations (e.g., substance abuse, mental health, and multiservice). The content of the structured assessment reflected system elements with proven effectiveness that have been included in guidelines and best practices recommendations. Detailed information was collected on the implementation strategies. RESULTS: This study found considerable attention to systems that support cessation services in diverse healthcare organizations, but much remains to be done. There is a wide diversity of implementation strategies employed, with varied degrees of sophistication. CONCLUSIONS: A major challenge is to develop systems capable of providing population-based feedback to, and between, providers, which will enable further quality improvement efforts.