1. 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.

2. 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

3. The University of Georgia 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. The University of Georgia 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. The University of Georgia 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

6. The University of Georgia Is the racial/ethnic composition of treatment organizations’ caseloads associated with the availability of evidence-based treatment practices?

7. The University of Georgia 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. The University of Georgia Is the racial/ethnic composition of centers’ caseloads associated with the adoption of addiction treatment medications?

9. The University of Georgia 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. The University of Georgia 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

11. The University of Georgia 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. The University of Georgia 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

13. The University of Georgia 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. The University of Georgia 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. The University of Georgia 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. The University of Georgia Results: Racial/Ethnic Differences and Organizational Characteristics

17. The University of Georgia 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. The University of Georgia 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. The University of Georgia Typology of Medication Adoption

20. The University of Georgia 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

21. The University of Georgia 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

22. The University of Georgia 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

23. The University of Georgia 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

24. The University of Georgia 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

25. The University of Georgia 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. The University of Georgia 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. The University of Georgia 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 University of Georgia 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