While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Millions of lives are derailed each year in America by addiction to drugs and alcohol. As of 2011, an estimated 20.6 million people met the criteria for drug or alcohol abuse and dependence, according to the Substance Abuse and Mental Health Services Administration.
And while the human costs of addiction are devastating for individuals and families, the National Institute on Drug Abuse reports that society loses more than 3 billion a year in health care expenses, lost productivity and other problems related to drug and alcohol abuse. As daunting as the numbers may be, there is one fact on which mental health care experts agree—substance abuse treatment can be extremely effective. A recent study from the Open Society Foundation also reports that “addiction treatment significantly reduces emergency room, inpatient and total health care costs.”
“We know that people who complete treatment programs, whether they are residential or outpatient, are more likely to experience future success. They have lower rates of homelessness, are more likely to stay employed and abstain from substance abuse,” says Brendan Saloner, PhD, a 2012-2014 scholar in the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program at the University of Pennsylvania. He specializes in health policy and health services research. “I’ve long been interested in access to mental health and substance abuse treatment, but research tells us that those services are not being used effectively and that there are disparities between racial and ethnic groups,” Saloner adds. “My work is focused on how we can improve addiction treatment, especially now that the Affordable Care Act stands to provide increased Medicaid funding for mental health treatment and cultural competency training for providers.”
Disparities in Treatment Completion
While public insurance and sliding-scale fee structures have increased access to residential treatment programs, there are still significant disparities in who manages to complete, and therefore fully benefit from, this type of therapy. In research published in the January 7 issue of Health Affairs, Saloner and his co-author, Benjamin Lê Cook, MPH, PhD, a scientist at the Center for Multicultural Mental Health Research at Harvard University, report racial disparities in treatment completion are exacerbated, among certain groups, by lower socioeconomic status. “We analyzed 1 million individuals discharged from publicly funded substance abuse facilities in the United States, and found that more than one-third did not complete treatment,” Saloner says.
Hispanics, Blacks and Native Americans, who constitute approximately 40 percent of the admissions to publicly funded substance abuse treatment programs, are the groups most likely to have poor treatment outcomes, Saloner and Cook report. “Blacks and Hispanics were 3.5 to 8.1 percent less likely than Whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percent less likely to complete alcohol treatment. Only Asian Americans fared better than Whites for both types of treatment.”
Saloner and Cook’s analysis offers a unique perspective because their study included a large, national population. “Most treatment studies focus on small, selective samples, but we used the Treatment Episodes Datasets to assess what happens to people when they are discharged from treatment for any one of several reasons,” Saloner says.
Barriers to Beating Addiction
Economic status may seem like a straightforward explanation for the disparities among different ethnic and racial groups working their way through treatment programs. But Saloner explains that not only are there significant differences between the groups, but poverty also may contribute to a host of factors that may inhibit treatment completion.
“We see very substantial variations between ethnic groups in our data. Levels of employment, educational attainment, and homelessness or housing status explained some of the differences between Whites and the other groups, but not all. Native Americans, for example, were far less likely to complete alcohol treatment, but not drug treatment, and socioeconomic factors did not link to treatment completion,” Saloner says.
“Asian Americans tended to do better than Whites in all forms of addiction treatment, but again, socioeconomic levels did not explain the difference. Yet for Blacks and Hispanics, markers of socioeconomic status, particularly housing instability and unemployment, accounted for most of the disparities in treatment completion,” he says.
Looking for Answers
“Our point is not that the treatment system is terrible,” Saloner says. “It is that the system could clearly do a better job of addressing the treatment needs of people from different backgrounds.” Addressing many of the pressures people face may be key to making treatment completion more likely for some groups, he advises: “Imagine the impact of being able to step away from homelessness or other stressors. That’s a very important part of this.”
Saloner and Cook’s analysis also considered the possibly that program completion rates were affected by negative experiences some groups encounter when entering the treatment system, such as discrimination or a lack a cultural competency on the part of providers.
In his next project, Saloner will look at adolescents and children in Medicaid programs to see what kind of care they are receiving. He credits his “phenomenal” RWJF Health & Society Scholar program mentors with teaching him to be “very strategic about making my research relevant to policy-makers at this very critical time for health care reform.”
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