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Racial Disparities in Access to Addiction Treatment Medications

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... differences in the receipt of evidence-based, high-quality care for a wide range of conditions: ... into disparities in access to evidence-based treatment ... – PowerPoint PPT presentation

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Title: Racial Disparities in Access to Addiction Treatment Medications


1
Racial Disparities in Access to Addiction
Treatment Medications
  • Hannah K. Knudsen, Ph.D.
  • Lori J. Ducharme, Ph.D.
  • Paul M. Roman, Ph.D.

2
Racial Ethnic Disparities in Healthcare
  • Institute of Medicines report (2003), Unequal
    Treatment Confronting Racial and Ethnic
    Disparities in Healthcare, documents persistent
    healthcare disparities in the US
  • Racial and ethnic differences in the receipt of
    evidence-based, high-quality care for a wide
    range of conditions
  • Cardiovascular disease
  • Breast cancer
  • HIV/AIDS
  • Asthma
  • These differences in receipt of services have
    implications for long-term health greater risk
    of mortality among racial/ethnic minorities

3
Racial Ethnic Disparities Mental Health
Substance Abuse Treatment
  • Evidence of disparities in behavioral healthcare
  • Racial/ethnic disparities in access to specialty
    mental health services
  • Differences in receipt of psychotropic
    medications, such as lower likelihood of
    receiving state-of-the-art medications

4
Conventional Explanations of Disparities
  • There is a tendency of focusing on individuals as
    the level of analysis
  • Patient-level factors
  • Socio-economic status insurance coverage
  • Patient preferences lack of adherence to
    recommended treatment regimen
  • Neither explanation fully accounts for
    disparities
  • Physician-level factors
  • Indirect evidence that physician bias may
    influence their decision-making

5
A New Lens to Studying DisparitiesThe Roles of
Organizations
  • Organizations are the site of service delivery
  • Our focus is on specialty substance abuse
    treatment centers, not counselors in private
    practice or office-based physicians
  • Decisions about the availability of services
    occurs at the level of the organization
  • When organizations decide to not adopt
    innovations, this affects the quality of care
    received by clients
  • If organizations vary in the racial/ethnic
    composition of their caseloads, these decisions
    about service delivery translate into disparities
    in access to evidence-based treatment
  • This has largely been understudied

6
Is the racial/ethnic composition of treatment
organizations caseloads associated with the
availability of evidence-based treatment
practices?
7
Racial/Ethnic Disparities in Access to SSRIs
  • SSRIs represent an important front-line
    pharmacotherapy for clients with co-occurring
    substance abuse and depression (Nunes Levin,
    2004)
  • Treatment centers vary in their adoption of SSRIs
  • 66 of privately funded non-profits have adopted
  • 31 of publicly funded non-profits have adopted
  • Data from the National Treatment Center Study
    indicates a negative association between the
    percentage of minority clients in centers
    caseloads and the likelihood of SSRI adoption
  • Lower odds of adoption in centers with a greater
    percentage of minority clients
  • This difference persists after controlling for a
    range of organizational characteristics,
    including access to physician services center
    type (ownership reliance on public funding)

8
Is the racial/ethnic composition of centers
caseloads associated with the adoption of
addiction treatment medications?
9
Classifying Medication Adoption The Continuum
of Regulations
  • Medications for the treatment addiction can be
    grouped by regulatory hurdles to their adoption
  • A continuum of regulatory intensity
  • More intensively regulated, where
    centers/physicians must meet additional
    requirements methadone, buprenorphine
  • Less intensively regulated, where physicians can
    prescribe without additional regulatory
    requirements disulfiram, naltrexone

10
Typology of Medication Adoption
11
Research Questions
  • Is the racial/ethnic composition of treatment
    organizations caseloads associated with patterns
    of addiction treatment medication adoption?
  • Does this association hold when other
    organizational characteristics are controlled?

12
Sample
  • Data from the National Treatment Center Study
  • Community-based addiction treatment centers
  • Must offer a minimum of outpatient care (as
    defined by ASAM)
  • Two nationally representative samples
  • Publicly funded centers (n 363) gt 50 of
    revenues from government block grants/contracts
  • Response rate 80
  • Privately funded centers (n 401) lt50 of
    revenues from government block grants/contracts
  • Response rate 88
  • Data collected via face-to-face interviews with
    administrators and/or clinical directors
  • Complete data from n 677

13
Measures Methods
  • Typology of Medication Adoption
  • No adoption (reference category)
  • Only more intensely regulated medications
    methadone, LAAM, and/or buprenorphine
  • Only less intensely regulated medications
    disulfiram and/or naltrexone
  • Combination of both types of medications
  • Analytic technique Multinomial Logistic
    Regression
  • Examine the log-odds of three types of adoption
    relative to no adoption

14
Measures Organizational Characteristics
  • Percentage of caseload comprised of racial/ethnic
    minority clients
  • Percentage of clients with primary opiate
    dependence
  • Center type
  • Government-owned
  • Publicly funded non-profit (reference category)
  • Privately funded non-profit
  • For-profit
  • Organizational affiliation
  • Hospital-based
  • Community mental health center
  • Freestanding (reference category)
  • Size natural log-transformed number of employees
  • Age natural log-transformed years
  • Accreditation center is accredited by JCAHO or
    CARF

15
Measures Staffing Services
  • Physician Services
  • Physicians on staff
  • Physicians on contract
  • No access to physicians (reference category)
  • Levels of care
  • Offers inpatient detox (1 yes, 0 no)
  • Offers outpatient detox (1 yes, 0 no)
  • Offers inpatient treatment program (1 yes, 0
    no)
  • Offers residential treatment program (1 yes, 0
    no)
  • Offers outpatient treatment (PHP, IOP, OP, 1
    yes, 0 no)
  • 12-Step Treatment Model 1 yes, 0 no

16
ResultsRacial/Ethnic Differences and
Organizational Characteristics
17
Racial/Ethnic Composition by Center Type
  • Mean for the total sample 39.2
  • Similar to average reported in federal TEDS
    dataset
  • Public sector programs reported significantly
    greater percentages of racial/ethnic minority
    clients than private sector programs

18
Racial/Ethnic Composition by Organizational
Characteristics
  • Significantly lower racial/ethnic minority
    clients in
  • Centers offering inpatient detox
  • Centers offering inpatient treatment
  • Accredited centers
  • Hospital-based centers
  • Significantly greater racial/ethnic minority
    clients in
  • Centers with residential programs
  • No differences by
  • Center offers outpatient treatment or outpatient
    detox
  • Twelve-step treatment model
  • Availability of physicians
  • Center size or center age
  • of opiate dependent patients

19
Typology of Medication Adoption
20
Multinomial Logistic RegressionBivariate Results
  • More intensely regulated medications vs. No
    medications
  • racial/ethnic minority clients not significant
  • Less intensely regulated medications vs. No
    medications
  • Significant negative association (plt.001)
  • A standard deviation increase in racial/ethnic
    minority clients associated with 35.4 decrease
    in odds of this type of medication adoption
  • Both types of medications vs. No medications
  • Significant negative association (plt.001)
  • A standard deviation increase associated with
    39.5 decrease in odds of this type of medication
    adoption

21
Multinomial Logistic RegressionMultivariate
Results
  • Controlling for organizational characteristics,
    the percentage of racial/ethnic minority clients
    is still significantly associated with
  • The odds of adoption of less intensely regulated
    medications (vs. no meds)
  • SD change associated with 23.4 decrease in odds
    of adoption
  • The odds of adoption of both types of medications
    (vs. no meds)
  • SD change associated with 41.9 decrease in odds
    of adoption

22
Other Significant PredictorsMore intensely
regulated vs. No Meds
  • Greater adoption in government-owned vs. publicly
    funded non-profit
  • Center size increases odds of adoption
  • Presence of staff physician (vs. no physician)
    increases odds of adoption
  • Accredited centers more likely to adopt
  • Centers with residential programs less likely to
    adopt
  • Positive association between opiate clients and
    adoption

23
Other Significant PredictorsLess intensely
regulated vs. No meds
  • Greater adoption in government-owned vs. publicly
    funded non-profit
  • Greater adoption in for-profit vs. publicly
    funded non-profit
  • Greater adoption in hospital-based centers vs.
    freestanding
  • Presence of staff physician (vs. no physician)
    increases odds of adoption
  • Centers with outpatient programming more likely
    to adopt
  • Centers offering inpatient detox or outpatient
    detox more likely to adopt

24
Other Significant PredictorsBoth types of meds
vs. No meds
  • Center size increases odds of adoption
  • Presence of staff physician (vs. no physician)
    increases odds of adoption
  • Accredited centers more likely to adopt
  • Hospital-based centers more likely to adopt
  • Twelve-step programs less likely to adopt
  • Centers with residential programs less likely to
    adopt
  • Centers offering outpatient detox more likely to
    adopt
  • Positive association between opiate clients and
    adoption

25
Summary
  • The majority (60) of centers have not adopted
    addiction treatment medications
  • There is evidence of an association between the
    percentage of minority clients and the likelihood
    of medication adoption
  • Less regulated (e.g. disulfiram or naltrexone)
  • Combination of less regulated more regulated
    (e.g. methadone, buprenorphine)

26
Limitations
  • Cross-sectional data cannot establish causality
  • Lack of data on specific racial ethnic groups
  • Currently collecting data from publicly funded
    programs so will be able to re-examine these
    differences by groups
  • Focus on any use rather than implementation
  • This model does not address how routinely these
    medications are used

27
Conclusion
  • Future research should continue to examine if and
    how disparities operate at the level of
    organizations
  • These data suggest the need to consider whether
    there are additional racial and ethnic
    differences in access to evidence-based treatment
  • Psycho-social approaches
  • Wraparound services

28
  • The authors gratefully acknowledge the support of
    research funding from the National Institute on
    Drug Abuse (R01-DA-14482 and R01-DA-13110).
  • This presentation and other reports from the
    National Treatment Center Study are available at
    http//www.uga.edu/ntcs
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