August 2006

Grant Results

National Program

Substance Abuse Policy Research Program

SUMMARY

From November 1999 until June 2001, Philip Appel, Ph.D., and colleagues at the New York State Office of Alcoholism and Substance Abuse Services documented barriers to substance abuse treatment services for injection drug users in New York City and its northern suburbs.

Researchers also gathered suggestions regarding ways to address the barriers identified by injection drug users, street outreach workers, substance abuse treatment staff and government officials.

The project was part of the Robert Wood Johnson Foundation's (RWJF) national Substance Abuse Policy Research Program (SAPRP) (for more information see Grant Results).

Key Findings

  • Users of injection drugs, who were clients of street outreach programs, and other stakeholders in substance abuse treatment cited the following main barriers to treatment:
    • Family or personal problems or lack of desire for treatment.
    • Lack of insurance or Medicaid coverage or long waiting lists.
    • Lack of uniform admissions criteria.
    • Lack of transportation and treatment slots.
    • Insensitivity of social services staff and police.
  • Key suggestions offered for reducing treatment barriers include:
    • Admit people without insurance or Medicaid and people without identification or other documents to treatment programs.
    • Increase funding for transportation, treatment slots, staffing, training and case management.
    • Streamline admissions.
    • Offer educational and incentive programs for substance abuse treatment staff.

Funding
RWJF supported this project with a $348,808 grant to the Research Foundation for Mental Hygiene, which assists in research and training at the New York State Department of Mental Hygiene and its component agencies, including the Office of Alcoholism and Substance Abuse Services.

 See Grant Detail & Contact Information
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THE PROBLEM

People who are injection drug users are a major source of HIV/AIDS transmission, according to the federal Centers for Disease Control and Prevention.

In 1989–90, the New York State Office of Alcoholism and Substance Abuse Services (OASAS) developed street outreach programs to focus on harm reduction strategies, such as teaching users about safer injecting practices.

Street outreach staff also tried to help injection drug users enter substance abuse treatment, but both users and outreach staff said that they ran into many obstacles to treatment. Only 5 percent of heavily addicted injection drug users served by street outreach workers in New York City enroll in treatment.

Since injection drug users continue to be a major source of disease transmission, it is important for individuals and agencies involved in substance abuse treatment to identify and reduce those obstacles.

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THE PROJECT

The objectives of this project were to identify barriers in enrolling injection drug users in substance abuse treatment and to get suggestions for addressing those barriers.

Using four separate semi-structured questionnaires, Philip Appel, Ph.D., and colleagues at the New York State Office of Alcoholism and Substance Abuse Services conducted in-person interviews with:

  • Some 144 injection drug users who were clients of street outreach programs in New York City and its northern suburbs. Interviews covered topics such as medical, psychiatric and drug use history; HIV/AIDS risk behaviors; perceived barriers to entering treatment, and suggestions for making it easier to enroll in treatment.
  • Some 55 staff of street outreach programs. Interviews covered topics such as job duties, prior work experience, personal history of substance abuse treatment and HIV/AIDS status.

    Interviewers also asked staff to identify barriers to entering treatment, changes in barriers over the past 10 years and suggestions for reducing barriers.
  • Some 71 substance abuse treatment agency staff. Interviews covered topics such as job duties, prior work experience, personal history of treatment, HIV/AIDS status, program admission requirements and experience with street outreach referrals.

    Interviewers also asked staff to identify barriers to treatment, remedies to those barriers and the level of promise for each suggested remedy.
  • Some 11 officials in the New York Office of Alcoholism and Substance Abuse Services, the New York State Department of Health AIDS Institute and the New York City Human Resources Administration. Interviews covered topics such as job title, prior work experience, past or planned actions to address barriers and obstacles to treatment.

    Interviewers also asked officials to describe their views about substance abuse treatment services and the use of harm-reduction methods for combating disease transmission among injection drug users.

Appel and colleagues presented findings of the study at the 13th National AIDS Update Conference in March 2001.

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FINDINGS

Appel and colleagues reported the following findings in an article published in the American Journal of Drug and Alcohol Abuse (see the Bibliography for details). They reported some details in a report to RWJF, as noted below.

Findings From Interviews With Injection Drug Users

  • The people interviewed were active drug users.
    • All users had injected heroin in the prior week.
    • 32 percent had also injected cocaine.
    • 25 percent had injected "speedballs," a mixture of heroin and cocaine.
    • Nearly 75 percent injected drugs three or more times per day.
    • 46 percent had previous episodes of drug treatment lasting at least two weeks.
  • The main reasons injection drug users gave for not entering treatment were:
    • Family or personal problems, such as not wanting to tell family members about the drug use or being the sole breadwinner (22.9 percent of users).
    • No desire for treatment or the demands of addiction were rewarding or incompatible with treatment requirements (17.7 percent of users).
    • Lack of insurance or Medicaid (17.2 percent of users).
  • When asked if any of 21 obstacles applied to them, more than 40 percent of the people interviewed said that:
    • It was too much of a "hassle" to apply for Medicaid (47.9 percent of users).
    • They had to wait too long to enter the particular program they wanted (43.8 percent of users).
    • They were not able to get into treatment when they wanted to go (42 percent).
  • The main suggestions drug users offered to help them enter treatment were:
    • Admit people without insurance or Medicaid to treatment programs (29.9 percent of users).
    • Admit people who do not have identification or other documents to treatment programs (22.9 percent of users).

Findings From Interviews With Staff of Street Outreach Programs

  • Nearly 71 percent of street outreach staff had personal histories of substance abuse treatment.
  • Outreach staff said that the main barriers to treatment for injection drug users were (figures reported in report to RWJF):
    • Lack of insurance or Medicaid coverage or long waiting lists (74.5 percent of staff).
    • Lack of uniform admissions criteria (63.6 percent of staff).
    • Lack of personal identification, transportation and treatment slots for outreach referrals; and police or social services staff insensitivity (50 percent or more of staff).
  • The main suggestions outreach staff offered for reducing treatment barriers were:
    • Increase funds for services such as transportation, treatment slots, staffing and training (100 percent of staff).
    • Expedite treatment enrollment by admitting drug users without identification or insurance and liberalizing welfare reform mandates that affect eligibility (80 percent of staff).
    • Increase interagency cooperation and modify treatment programs to better meet client needs (60 percent of staff).

Findings From Interviews With Substance Abuse Treatment Program Staff:

  • Some 42 percent of substance abuse treatment staff had personal histories of substance abuse treatment.
  • Substance abuse treatment staff said the main barriers to treatment were:
    • Client-based factors, such as not being ready for or motivated to enter treatment (75 percent of staff).
    • Social-services factors, such as insensitive welfare workers (75 percent of staff).
    • Treatment program factors, such as red tape, waiting lists and preference for Medicaid-eligible clients (62 percent of staff).
  • The main suggestions treatment staff offered for reducing treatment barriers were:
    • Increase funds for treatment (80.3 percent).
    • Streamline admissions to treatment (77 percent of staff).
    • Offer educational and incentive programs for staff (61 percent).

Findings from Interviews with Government Officials:

  • Government officials said the main barriers to treatment were:
    • Lack of client readiness to enter treatment.
    • Lack of treatment resources.
    • Treatment program requirements.
  • Government officials offered the following agency-specific suggestions for reducing treatment barriers (because only 11 officials were interviewed, percentages for responses were not computed):
    • The Office of Alcoholism and Substance Abuse Services should:
      • Review its abstinence-only policy.
      • Address the place of harm reduction in supporting substance abuse prevention and treatment.
    • The state should increase resources in the areas of:
      • Slots for women, children and detoxification.
      • Case management, transportation and automation.
    • Treatment programs should:
      • Provide comprehensive services.
      • Allow transition periods during which clients may still be using drugs.
      • Enforce existing policies that require them to admit clients regardless of ability to pay.
    • All relevant agencies should:
      • Establish consumer advisory boards.
      • Educate agency policy-makers about harm reduction.
      • Educate staff and physicians about the negative effects of prejudicial attitudes towards injection drug users.

Limitations

Appel reported the following limitations of the study.

  • It is not clear, from the findings, to what extent the obstacles cited by injection drug users are actually just rationalizations for a lack of readiness or motivation for treatment. Nearly 20 percent of users said that there were no obstacles to treatment, they had no desire for treatment or the demand or rewards of addiction were not compatible with treatment. Treatment staff also cited lack of client readiness or motivation as a major obstacle but they cited policies, practices and resource limitations as barriers at least as often.
  • Researchers asked each group of interviewees somewhat different questions regarding obstacles to treatment. Because questions were not standard across all groups, it is difficult to compare responses between groups.
  • Because such a small number of agency staff were interviewed, caution should be taken in drawing conclusions regarding agencies in general.

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CONCLUSIONS

Project researchers offered summary conclusions about study findings in a report to RWJF:

  • Lack of insurance or Medicaid and not having identification or documentation were consistently reported as barriers to enrollment in substance abuse treatment programs. However, the prominence given to these barriers varied greatly among the interview groups. Outreach and treatment program staff highlighted them, clients mentioned them, and government agencies put little emphasis on them.
  • The need for additional resources was another consistent theme. Needed resources included: treatment "slots," appropriate slots, incentives for outreach and treatment staff and resources for training, services and organizational development.

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AFTER THE GRANT

Appel and colleagues reported findings in a 2004 article in the American Journal of Drug and Alcohol Abuse and presented findings to staff of the New York State Office of Alcoholism and Substance Abuse Services in 2001, with a later distribution of findings and recommendations to stakeholders.

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GRANT DETAILS & CONTACT INFORMATION

Project

Study of Barriers to Referring the At-Risk, Street Outreach Population to Substance Abuse Treatment

Grantee

Research Foundation for Mental Hygiene (Albany,  NY)

  • Amount: $ 348,808
    Dates: November 1999 to June 2001
    ID#:  037859

Contact

Philip W. Appel, Ph.D.
(646) 728-4626
appelp@oasas.state.ny.us

Web Site

http://www.saprp.org
http://www.saprp.org/grant_publications.cfm?appID=19

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Appel PW, Ellison AA, Jansky HK and Oldak R. "Barriers to Enrollment in Drug Abuse Treatment and Suggestions for Reducing Them: Opinions of Drug Injecting Street Outreach Clients and Other System Stakeholders." American Journal of Drug and Alcohol Abuse, 30(1): 129–153, 2004. Abstract available online.

Survey Instruments

"Client Interview Schedule," New York State Office of Alcoholism and Substance Abuse Services, fielded spring and summer 2000.

"Outreach Staff Interview Schedule," New York State Office of Alcoholism and Substance Abuse Services, fielded spring and summer 2000.

"Treatment Program Staff Interview Schedule," New York State Office of Alcoholism and Substance Abuse Services, fielded fall and winter 2000.

"Agency Representative Interview Schedule," New York State Office of Alcoholism and Substance Abuse Services, fielded winter and spring 2001.

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Report prepared by: Mary Nakashian
Reviewed by: Mary B. Geisz
Reviewed by: Molly McKaughan
Program Officer: Victor A. Capoccia
Program Officer: Michelle A. Larkin

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