The University of Georgia

Racial Disparities in Access to Addiction Treatment Medications

Hannah K. Knudsen, Ph.D.Lori J. Ducharme, Ph.D.Paul M. Roman, Ph.D.

The University of Georgia

Racial & Ethnic Disparities in Healthcare

• Institute of Medicine’s 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

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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

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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

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A New Lens to Studying Disparities:

The 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

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Is the racial/ethnic composition of treatment organizations’

caseloads associated with the availability of evidence-based

treatment practices?

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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)

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Is the racial/ethnic composition of centers’ caseloads associated with the adoption of addiction

treatment medications?

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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

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Typology of Medication Adoption

Center Does Not Use Medications

(Reference Category)

Center Uses Only More Intensely

Regulated Medications (e.g.

methadone, buprenorphine)

Center Uses Only Less Intensely

Regulated Medications (e.g.

disulfiram, naltrexone)

Center Uses Both Types of Medications

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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?

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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): > 50% of revenues from government block grants/contracts

Response rate = 80%– Privately funded centers (n = 401): <50% 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

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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”

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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

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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

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Results:Racial/Ethnic Differences and Organizational Characteristics

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Racial/Ethnic Composition by Center Type

45%50%

30% 30%

0%

20%

40%

60%

Gov-Ow

ned

Public

Non-

Profi

tPr

ivate N

on-P

rofit

For-P

rofit

• 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

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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

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Typology of Medication Adoption

60.0%

7.1%

21.1%

11.8%

No Meds

More RegulatedMedsLess RegulatedMedsBoth Types

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Multinomial Logistic Regression:Bivariate Results

• More intensely regulated medications vs. No medications– % racial/ethnic minority clients not significant

• Less intensely regulated medications vs. No medications– Significant negative association (p<.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 (p<.001)– A standard deviation increase associated with 39.5%

decrease in odds of this type of medication adoption

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Multinomial Logistic Regression:Multivariate 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

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Other Significant Predictors:More 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

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Other Significant Predictors:Less 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

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Other Significant Predictors:Both 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

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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)

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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

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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

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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