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BACKGROUND Rural residents face significant barriers in accessing mental health services. As the need for these services increases and greater emphasis is put on telemedicine, examining geographic availability of mental health facilities and facilitators of telemedicine utilization is critical. OBJECTIVE To examine geographic variations in driving time to mental health facilities, digital access to telehealth services, and household crowdedness. METHODS This cross-sectional study used ZIP Code Tabulation Area (ZCTA)-level data from the 2015-2019 American Community Survey and 2021 SAMHSA Behavioral Health Treatment Services Locator to examine rural-urban differences in driving times to specialty mental health facilities, digital technology, and ZCTA-level household crowdedness. RESULTS Driving to outpatient facilities took longer in rural areas, with 8,545 (86.5%) of small rural ZCTAs and 3,535 (74.6%) of large rural ZCTAs being > 30 minutes from outpatient care, versus 7,655 (43.7%) of urban ZCTAs. Within those > 30 minutes, 522,154 (16.5%) rural households versus 237,800 (11.9%) urban households had no digital devices. Multivariable results show greater driving times to any mental health facility for small/isolated rural areas (8.6 minutes; 95% confidence interval CI, 8.2-9.1) than for urban areas. CONCLUSIONS Rural communities are farther from mental health facilities and have lower digital access than urban communities.

Coordinated care models, such as the Medicaid health home, may be well positioned to identify and address addiction, yet little is known about the strategies health home plans use to identify and treat this condition. This study examined state requirements of active Medicaid health home plans.Content analyses of all 35 active Medicaid health home plans were conducted to identify state requirements related to enrollment eligibility; provision of addiction screening, treatment, and prevention services; inclusion of addiction treatment professionals within the health home provider care team; and outcomes monitoring.Apart from health homes specifically focused on addiction, few states require health home plans to screen (44% of primary care-based and 33% of psychiatric health homes), treat (0% and 13%, respectively), and monitor treatment services for addiction (25% and 13%, respectively).Limited screening and treatment of addiction within health homes may limit the model's effectiveness in improving overall health.

ImportanceExpanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated with buprenorphine dispensing.ObjectiveTo examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents.Design, Setting, and ParticipantsThis cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder.ExposuresState implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined.Main Outcomes and MeasuresThe main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023.ResultsThe mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 [95% CI, 2.36-14.64] months in year 1 to 14.43 [95% CI, 2.61-26.26] months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 [95% CI, 3.17-10.86] months in the first year to 11.43 [95% CI, 0.61-22.25] months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents.Conclusions and RelevanceIn this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.

Active social work leadership is necessary to achieve national goals of health equity. Indeed, the nation’s health depends on the development of this next wave of interprofessional and transdisciplinary collaboration (McGovern, Miller, & Hughes-Cromwick, 2014). This chapter describes a “geography of science” approach that draws upon diverse disciplines, community leaders, and theoretical and community-center perspectives. Social work, must train professionals in how improve availability and access to the social determinants of good health. This includes understand how racism constitutes an important social determinant of health. We must also educate allied professionals to develop the practice and research tools, community partnerships, and localized programs necessary to combat social and economic inequities. Ten priorities for changing health systems to achieve equitable health care are advanced. Finally, to secure true, sustainable, population-based health changes, social work must assist the health professions to unite and develop transdisciplinary approaches to addressing the multilayered contributions of political, economic, and social determinants of population health inequities.

In 2016 only 13.8 percent of substance use disorder treatment programs offered medication treatment for opioid use disorder for older adults who used Medicare to pay for treatment. With increasing ...

Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.

ImportanceMedicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans.ObjectiveTo compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states.Design, Setting, and ParticipantsThis cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018.Main Outcomes and MeasuresFor each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022.ResultsCoverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA.Conclusions and RelevanceThis cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries’ access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation’s Medicaid programs.

In 2018, the Trump Administration took the unprecedented step of allowing states to impose work requirements as a condition of Medicaid eligibility. States can apply for a demonstration waiver to require Medicaid beneficiaries aged 19-64 who do not meet exemption criteria (e.g., disability, caring for a sick relative) to participate in "community engagement" activities, which include employment, volunteering, and enrollment in a qualifying education or job training program. Debate thus far has focused primarily around the important issue of whether such requirements are legal. Less attention has focused on another serious concern - namely, that work requirements could exacerbate the nation's most urgent public health crisis: the opioid epidemic. Many enrollees with opioid use disorder who are unable to meet states' community engagement criteria will not qualify for an exemption from the work requirements, and risk being dropped from Medicaid enrollment. Refusing health insurance to individuals who are unable to meet work requirements could result in significant losses in coverage among a highly vulnerable population. Implementing new barriers to Medicaid coverage will hinder the effectiveness of massive state and federal investments in improving access to evidence-based addiction treatment.

The Affordable Care Act (ACA) prompted sweeping changes to Medicaid, including expanding insurance coverage to an estimated 12 million previously uninsured Americans, and imposing new parity requirements on benefits for behavioral health services, including substance use disorder treatment. Yet, limited evidence suggests that these changes have reduced the number of uninsured in substance use disorder treatment, or increased access to substance use disorder treatment overall. This study links data from a nationally-representative study of outpatient substance use disorder treatment programs and a unique national survey of state Medicaid programs to capture changes in insurance coverage among substance use disorder treatment patients after ACA implementation. Medicaid expansion was associated with a 15.7-point increase in the percentage of patients insured by Medicaid in substance use disorder treatment programs and a 13.7-point decrease in the percentage uninsured. Restrictions in state Medicaid benefits and utilization policies were associated with a decreased percentage of Medicaid patients in treatment. Moreover, Medicaid expansion was not associated with a change in the total number of clients served over the study period. Our findings highlight the important role Medicaid has played in increasing insurance coverage for substance use disorder treatment.

Objectives. To assess states’ provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). Methods. We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. Results. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. Public Health Implications. The ACA’s infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA’s Medicaid expansion.

OBJECTIVE: Research has examined the effect of Medicaid expansion on access to physicians with buprenorphine waivers, but less attention has been paid to Medicaid’s impact on opioid use disorder medication availability within the specialty substance use disorder treatment system. To address this gap in the literature, this study examined the impact of Medicaid expansion on availability of opioid medications in specialty programs. METHODS: This study used data from the National Survey of the Substance Abuse Treatment Services (2002–2017), containing all known substance use disorder treatment programs in the United States, to examine the effect of Medicaid expansion on the availability of opioid use disorder medications by treatment program ownership type (publicly owned, private for profit, and private nonprofit) among opioid treatment programs (OTPs) and non-OTPs. RESULTS: The effects of Medicaid expansion were limited to nonprofit and for-profit OTPs. Medicaid expansion was associated with 135.1% and 57.5% increases in the number of nonprofit and for-profit OTPs offering injectable naltrexone, respectively, and with a 64.4% increase in the number of nonprofit OTPs offering buprenorphine. Nonprofit and for-profit OTPs compose

In 2016 only 13.8 percent of substance use disorder treatment programs offered medication treatment for opioid use disorder for older adults who used Medicare to pay for treatment. With increasing demand for treatment among older adults and a rapidly aging population, improved access to medication treatment for this population is needed.

Context: In contrast to the Affordable Care Act, some have suggested the opioid epidemic represents an area of bipartisanship. This raises an important question: to what extent are Democrat-led and Republican-led states different or similar in their policy responses to the opioid epidemic? Methods: Three main methodological approaches were used to assess state-level policy responses to the opioid epidemic: a legislative analysis across all 50 states, an online survey of 50 state Medicaid agencies, and in-depth case studies with policy stakeholders in five states. Findings: Conservative states pursue hidden and targeted Medicaid expansions, and a number of legislative initiatives, to address the opioid crisis. However, the total fiscal commitment among these Republican-led states pales in comparison to states that adopt the ACA Medicaid expansion. Because the state legislative initiatives do not provide treatment, these states spend substantially less than states with Democratic control. Conclusions: Rather than persistently working to retrench all programs, conservatives have relied on policy designs that emphasize devolution, fragmentation, and inequality to both expand and retrench benefits. This strategy, which allocates benefits differentially to different social groups and obfuscates responsibility, allows conservatives to avoid political blame typically associated with retrenchment.

OBJECTIVE: To examine whether the number of outpatient addiction programs accepting Medicaid in South Carolina counties is linked to repeat use of the emergency department for addiction-related conditions. METHODS: The study included the population all adult Medicaid enrollees (n = 2,401) in South Carolina with at least one addiction-related emergency service episode in 2012 or 2013. We used a random effects logistic regression model to examine the association between outpatient addiction treatment availability and repeat use of addiction-related emergency services by Medicaid enrollees. RESULTS: Enrollees in counties with two or more programs that accepted Medicaid were less likely to have a repeat addiction-related emergency service episode than enrollees residing in counties with only one program that accepted Medicaid. CONCLUSIONS: Availability of outpatient addiction treatment may reduce need for addiction-related emergency services. Research is needed to explore potential causal mechanisms underlying this observed relationship.

Objective To assess the relationship of restrictions on Medicaid benefits for addiction treatment to Medicaid acceptance among addiction treatment programs. Data sources We collected primary data from the 2013–2014 wave of the National Drug Abuse Treatment System Survey. Study design We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs. Data collection Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine. Principal findings Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states. Conclusions Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.

Objectives. To examine how utilization restrictions on state Medicaid benefits for buprenorphine are related to addiction treatment programs’ decision to offer the drug. Methods. We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability. Results. The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87). Conclusions. Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. Public Health Implications. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.

OBJECTIVE: The study examined whether the use of opioid agonist therapy (OAT) in treatment of opioid use disorder in specialty substance use treatment settings increased following Medicaid expansion. METHODS: Administrative data on 943,430 admissions from the Treatment Episodes Dataset-Admissions 2010-2016 were used to examine the association of Medicaid expansion with the use of OAT, and to assess whether this association was mediated by increased number of admissions with Medicaid. RESULTS: OAT use in expansion state patients with opioid use disorder increased from 39.1% in 2010-2013 to 50.2% in 2014-2016, while the corresponding increase in non-expansion states was from 39.9% to 40.5%. The effect of Medicaid expansion on OAT use was mainly mediated through a larger number of admissions with Medicaid coverage. CONCLUSIONS: As the nation grapples with the opioid epidemic, expanding Medicaid coverage has the potential to promote greater access to this evidence-based treatment.

In this mixed-method study, we examined coordination of mental health and public health services in addiction health services (AHS) in low-income racial and ethnic minority communities in 2011 and 2013. Data from surveys and semistructured interviews were used to evaluate the extent to which environmental and organizational characteristics influenced the likelihood of high coordination with mental health and public health providers among outpatient AHS programs. Coordination was defined and measured as the frequency of interorganizational contact among AHS programs and mental health and public health providers. The analytic sample consisted of 112 programs at Time 1 (T1) and 122 programs at Time 2 (T2), with 61 programs included in both periods of data collection. Forty-three percent of AHS programs reported high frequency of coordination with mental health providers at T1 compared to 66% at T2. Thirty-one percent of programs reported high frequency of coordination with public health services at T1 compared with 54% at T2. Programs with culturally responsive resources and community linkages were more likely to report high coordination with both services. Qualitative analysis highlighted the role of leadership in leveraging funding and developing creative solutions to deliver coordinated care. Overall, our findings suggest that AHS program funding, leadership, and cultural competence may be important drivers of program capacity to improve coordination with health service providers to serve minorities in an era of health care reform.

The Affordable Care Act (ACA) established a minimum standard of insurance benefits for addiction treatment and expanded federal parity regulations to selected Medicaid benefit plans, which required state Medicaid programs to make changes to their addiction treatment benefits. We surveyed Medicaid programs in all fifty states and the District of Columbia regarding their addiction treatment benefits and utilization controls in standard and alternative benefit plans in 2014 and 2017, when plans were subject to ACA parity requirements. The number of state plans that provided benefits for residential treatment and opioid use disorder medications increased substantially. States imposing annual service limits on outpatient addiction treatment decreased by over 50 percent. Fewer states required preauthorization for services, with the largest reductions for medications treating opioid use disorder. The ACA may have prompted state Medicaid programs to expand addiction treatment benefits and reduce utilization controls in alternative benefit plans. This trend was also observed among standard Medicaid plans not subject to ACA parity laws, which suggests a potential spillover effect.

More than 60 million Americans experience devastating one-two punches to their health -- they have inadequate access to basic health care while also enduring the effects of discrimination, poverty, and dangerous environments that accelerate higher rates of illness. Innovative and evidence-based social strategies can improve health care and lead to broad gains in the health of our entire society.

Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations.How states regulate SUD treatment benefits offered by QHPs has implications for the accessibility and quality of care. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls.Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey.States varied widely in regulations on QHPs' administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used.Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.

OBJECTIVE: As the United States grapples with an opioid epidemic, expanding access to effective opioid use disorder treatment is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This paper examines the relationship between state targeted funding and technical assistance and adoption of three opioid use disorder treatment medications: oral naltrexone, injectable naltrexone, and buprenorphine. METHODS: This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from Single State Agencies in 49 states and DC (98% response). Logistic regression was used to examine the relationship of Single State Agency targeted funding and technical assistance for opioid use disorder treatment medications to their availability among programs. RESULTS: State targeted funding was associated with increased program-level adoption of oral naltrexone (Adjusted Odds Ratio [AOR], 3.14; 95% CI=1.49-6.60, p=.004) and buprenorphine (AOR= 2.47, 95% CI=.31-4.67; p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR= 1.18, 95% CI=1.00-1.39; p=.049). CONCLUSIONS: State targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, Single State Agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

Over the past fifty years Medicaid has taken divergent paths in financing mental health and addiction treatment. In mental health, Medicaid became the dominant source of funding and had a profound impact on the organization and delivery of services. But it played a much more modest role in addiction treatment. This is poised to change, as the Affordable Care Act is expected to dramatically expand Medicaid’s role in financing addiction services. In this article we consider the different paths these two treatment systems have taken since 1965 and identify strategic lessons that the addiction treatment system might take from mental health’s experience under Medicaid. These lessons include leveraging optional coverage categories to tailor Medicaid to the unique needs of the addiction treatment system, providing incentives to addiction treatment programs to create and deliver high-quality alternatives to inpatient treatment, and using targeted Medicaid licensure standards to increase the quality of addiction services.

The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA's promise to improve access to and quality of addiction treatment.

Emerging adults have the highest prevalence of substance use disorders (SUD) of any age group, and only a fraction of those emerging adults in need of SUD treatment ever receive it. However, the Affordable Care Act (ACA) has dramatically increased the number of emerging adults with health insurance coverage for SUD in the United States. In this chapter, we examine how several provisions of the ACA, including Medicaid expansion, the dependent coverage mandate, and the establishment of healthcare marketplaces, have increased emerging adults’ access to quality SUD treatment. On the whole, the ACA has significantly increased access to SUD treatment among emerging adults. However, addressing existing barriers to effective implementation, including issues related to the capacity of our current SUD treatment system, socioeconomic barriers, public outreach and awareness, and variation in treatment access and quality, will prove vital in securing long-term success of the ACA.

Objective To examine county-level geographic variation in treatment admissions among opioid treatment programs (OTPs) that accept Medicaid in the continental United States. Data Sources/Study Setting Data come from the 2012 National Survey of Substance Abuse Treatment Services. Study Design/Data Collection We used local measures of spatial autocorrelation (LISA) analysis to identify (1) clusters of counties with higher and lower than average rates of opioid use disorders and (2) clusters of counties with higher and lower than average treatment admissions among OTPs that accept Medicaid, adjusting for county population size. Principal Findings Our results reveal several clusters of counties with higher than average rates of opioid use disorder (OUD) and lower than average treatment admissions among OTPs that accept Medicaid. These clusters are highly concentrated in the Southeast region of the country and include Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee. Conclusions Medicaid enrollees in areas in the Southeast have the largest gaps between county-level OUD rates and estimated county-level capacity for treatment, as measured by county-level total treatment admissions among OTPs that accept Medicaid. Policy makers should consider strategies to increase the availability of OTPs with the capacity to serve Medicaid enrollees.

This study examined gender differences within Black, Latino, and White subgroups in the utilization of comprehensive services and their relation to posttreatment substance use. Survey data were collected during the National Treatment Improvement Evaluation Study (NTIES), a prospective, longitudinal, multisite study of substance abuse treatment programs and their clients in the United States. The analytic sample consisted of 1,812 Blacks (734 women and 1,078 men), 486 Latinos (147 women and 339 men), and 844 Whites (147 women and 339 men) from 59 service delivery organizations. Results related to service utilization indicated that compared to men, women in all racial and ethnic groups needed and received more services targeted to their needs and reported more positive relations with service providers. Gender was a significant moderator of the relationship between service receipt and treatment outcomes for all racial and ethnic groups, but especially for the Latino subsample. Findings point to the need to consider race-specific gender differences in the development of culturally competent, comprehensive substance abuse treatment.

The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013–14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations.

The Affordable Care Act (ACA) (full title: The Patient Protection and Affordable Care Act) (P.L. 111-148) will generate sweeping changes in the financing, organization, and accessibility of health and social services in the United States. The expansion of Medicaid and the establishment of state health insurance exchanges (HIEs) will vastly expand insurance access in the United States, with an estimated 30 million Americans gaining coverage (Banthin et al., 2012). The emphasis on integrated models of care, including patient-centered medical homes and accountable care organizations, introduces new opportunities to improve care coordination, reduce unnecessary service use, and make health care more cost-effective. Realizing these changes relies on the work of many health care professions. In this editorial, we make a case for how the social work profession can forge a leadership role in implementing this historic legislation. SOCIAL WORK EXPERTISE AND THE ACA Because the ACA is so bold and ambitious, it is important to consider how the unique skills and knowledge bases of social work and other health care professions align with its objectives and goals. An integrated approach is needed to maximize the ACA's potential to improve the health of the population. Four central qualities of the social work profession make it uniquely suited to advance a number of the objectives and goals of the ACA. First, social work situates individuals in the social contexts in which they live. Social workers understand that individuals are part of social networks, neighborhoods, and communities that influence their health choices and participation in health care. Understanding these social relationships provides us with insight into health behaviors and health outcomes that is necessary to achieve population health goals. Social workers likewise understand the relationship between health, education, employment, and other systems that form the nexus from which resources can be drawn to protect, maintain, and restore health. Social workers are familiar with the complex and overlapping systems that must be negotiated to ensure that the social, psychological, and economic needs of individuals and groups are addressed in a way that underscores optimal health. For instance, social workers know how to ensure that patients have what they need from multiple systems upon discharge, that discharge instructions are understood, and that resources are in place to ensure that those instructions can be followed. This knowledge is essential for avoiding unnecessary readmissions--events subject to financial penalties under the ACA. In a related sense, social work is guided by an evidence base that is informed by rigorous research within communities and collective wisdom gleaned from over a century of social work practice. Of importance is social workers' research to understand how mental health and physical health interact to enhance or impede functioning and patients' participation in health care treatment. Social workers devise plans based on knowledge of how the two interact and can help to ensure that the communication occurs that underlies optimal, sustained functioning and wellness. Evidence-based social work practice begins where individuals and groups are, in a way that is sensitive to cultural beliefs and health literacy. This orientation helps to ensure that recommendations for disease prevention and care management are understood and that patients and families are able to follow instructions when individuals become ill. It is important to consider one additional quality of social work, not because it is directed at those who will be covered by the ACA, but because it considers those who will not be covered. Approximately 29 million Americans will still lack health insurance after the ACA is fully instituted (Banthin et al., 2012). Social workers historically have targeted their services to such disenfranchised groups, including those who do not have a stable place in society, may lack housing and other basic services, and have no or irregular contact with the health system. …

Medications for treatment of substance use disorders are underutilized in treatment programs in the United States. Little is known about how insurance enrollment within states affects treatment program decisions about whether to offer medications. The primary objective of the study was to examine the impact of health insurance enrollment on availability of substance use disorder medications among treatment programs.Data from the 2012 National Survey of Substance Abuse Treatment Services, National Survey on Drug Use and Health, American Community Survey, Area Health Resource File, and the Substance Abuse and Mental Health Services Administration were combined to examine the impact of state insurance enrollment on availability of substance use disorder medications in treatment programs (N=9,888). A two-level, random-intercept logistic regression model was estimated to account for potential unobserved heterogeneity among treatment programs nested in states.The percentage of state residents with employer-based insurance and Medicaid was associated with greater odds of offering at least one medication among treatment programs. A 5% increase in the rate of private insurance enrollment was associated with a 7.7% increase in the probability of offering at least one medication, and a 5% increase in the rate of state Medicaid enrollment was associated with a 9.3% increase in the probability of offering at least one medication.Results point to the potential significance of health insurance enrollment in shaping the availability of substance use disorder medications. Significant expansions in health insurance enrollment spurred by the Affordable Care Act have the potential to increase access to medications for many Americans.

Wait time is among the most commonly cited barriers to access among individuals seeking entry to substance abuse treatment, yet relatively little is known about what contributes to it.To address this gap, this study draws from a national sample of substance abuse treatment clients and programs to estimate the proportion of clients entering treatment who waited more than 1 month to receive it (outpatient, residential, or methadone) and to identify client and program characteristics associated with wait time.This study used data from the National Treatment Improvement Evaluation Study (1992-1997). The data include 2920 clients from 57 substance abuse treatment programs. Generalized linear modeling was used to identify client and program characteristics associated with wait time to treatment entry.Results of modeling indicate that being African-American (OR: 1.40; CI: 1.04, 1.88), being referred by criminal justice (OR: 1.70; CI: 1.18, 2.43), and receiving methadone (OR: 3.90; CI: 1.00, 15.16) were associated with increased odds of waiting more than 1 month. Conversely, having a diagnosis of HIV/AIDS (OR: 0.38; CI: 0.19, 0.77) was associated with decreased odds of waiting for more than 1 month.A significant proportion of clients waited more than 1 month on enter treatment. Greater odds of such wait times were associated with being African-American, criminal justice-referred, and receiving methadone.This study is the first to use a national sample to examine the prevalence of wait time to substance abuse treatment entry and to identify client and program characteristics associated with it.

This study examines substance use severity, levels of social and health service utilization, and the impact of service utilization on treatment outcomes for sexual minorities versus non-minorities. The sample included 3,094 clients from the National Treatment Improvement Evaluation Study (NTIES). Substance use severity among sexual minorities and non-sexual minorities was similar at treatment entry and at 12 months post-discharge. Differences in social and health service utilization were significant for substance abuse counseling and health services. Significant interactions between sexuality and access services and sexuality and mental health services were also found. Practice and research implications are discussed.

This systematic review reports on the association of the client-provider relationship with service outcomes across 3 service sectors: substance abuse, child welfare, and mental health. The review includes 60 research reports meeting inclusion criteria: 25 in substance abuse, 7 in child welfare, and 28 in mental health. For each social service sector, we analyze the association of the client-provider relationship to intermediate and ultimate outcomes. In addition, we examine potential moderating mechanisms of rater type (i.e., client, provider, and observer) and treatment setting (i.e., inpatient, outpatient, other). Social services research increasingly seeks to identify the active elements that affect outcomes common to all interventions. Results suggest the client-provider relationship is a consistent predictor of client retention in treatment and a somewhat less-consistent predictor of ultimate outcome across the 3 service sectors. These results contrast with recent findings from the psychotherapeutic ...

The authors reflect on changes involving substance use disorder (SUD) treatment under the U.S. Patient Protection and Affordable Care Act (ACA), and it mentions American President Barack Obama's public health legacy, as well as the potential impact that the ACA will have on an opioid epidemic in the country. Medications for opioid use disorder patients are examined, along with health insurance coverage for SUD treatment services and the U.S. 2008 Mental Health Parity and Addiction Equity Act.

We compared the race and ethnicity of individuals residing in states that did and did not expand Medicaid in 2014. Findings indicated that African Americans and Native Americans with substance use disorders who met new federal eligibility criteria for Medicaid were less likely than those of other racial and ethnic groups to live in states that expanded Medicaid. These findings suggest that the uneven expansion of Medicaid may exacerbate racial and ethnic disparities in insurance coverage for substance use disorder treatment.

As social work advances into the 21st century, dramatic increases in the aging of the U.S. population, shifting policy imperatives, and the emergence of new technologies have transformed the professional landscape in which social workers operate. To survive in today's world, social workers must be able to learn new skills and adapt to change. This article reviews the challenges facing the profession in transferring practice skills to social workers and describes the strategies of the Institute for Geriatric Social Work (IGSW) that address them. Well-designed training should provide a learning experience that is affordable, accessible and grounded in skill-based competencies. The challenge facing IGSW—and the broader social work community—is how to promote continuing education that maximizes these ends.

The real-time traffic adaptive control system (RT-TRACS) represents a new, state-of-the-art system in advanced traffic signal control. It was developed cooperatively by a team of U.S. academic, private, and public researchers under the guidance of FHWA. The system provides a framework to run multiple traffic control algorithms, existing ones as well as new adaptive algorithms, as they become available. The optimized policies for adaptive control (OPAC) strategy, which provides a dual capability of individual intersection control as well as coordinated control of intersections in a network, was the first adaptive algorithm implemented within the RT-TRACS framework. The operational features of the OPAC prototype version that was developed for RT-TRACS are presented, and its implementation in the Reston Parkway field research test bed in Northern Virginia is described. The implementation provided valuable insights into the performance of coordinated OPAC under various traffic conditions and site geometry. Observations indicate that the strategy was instrumental in reducing delays and stops, compared with a well-tuned fixed time system that was in place, while maintaining progression along the arterial. Valuable lessons were learned that should lead to improvements in future implementations of adaptive algorithms.

Although the Affordable Care Act was not designed with the opioid epidemic in mind, it provides valuable tools for expanding access to medication treatment — tools that will be taken away if the president and Congress deliver on their promise to repeal the ACA.

Medicaid’s intergovernmental design with a generous federal matching rate and substantial state discretion has fostered gradual but steady expansions of the program over time. Gradual growth creates a favorable political environment in which each expansion creates a political constituency for Medicaid—among provider groups and enrollees—who then fight against retrenchment. Yet, as program expenditures continue to increase, especially during fiscally distressed times, the partisan divide over the future direction of Medicaid becomes more stark. These are the political dynamics that will define how states struggle with the Affordable Care Act (ACA) Medicaid expansion and also how states attempt to provide long-term care financing and services under their Medicaid programs.

The Affordable Care Act will dramatically increase the number of Americans with Medicaid coverage for substance abuse treatment (SAT). Currently, few SAT providers accept Medicaid, and consequently, there is concern that newly-eligible Medicaid enrollees will have difficulty finding SAT providers willing to serve them. However, little is known about why few SAT providers accept Medicaid. In response, this study examines how features of state Medicaid coverage for SAT, including benefits, eligibility, and oversight, are associated with Medicaid acceptance among SAT providers. Medicaid acceptance was positively associated with the number of SAT services covered, and the number of optional categorical expansions implemented by the state. Requirements for physician involvement were associated with lower odds of acceptance. The results suggest that more generous Medicaid coverage may encourage SAT providers to accept Medicaid, but regulatory policies may inhibit their ability to do so.

Conventional traffic-control strategies have limitations in handling unanticipated traffic demands. An adaptive traffic-signal control is expected to mitigate this problem and improve overall system performance. Furthermore, with the increasing needs of evolving intelligent transportation systems, traffic signals are expected to provide significantly greater functionalities, which can be achieved only by adaptive control. A product of many years of development, Optimized Policies for Adaptive Control (OPAC) represents a significant step forward in adaptive signal-control research. The OPAC strategy was field-tested at a New Jersey site. The performance of OPAC was compared against a well-designed time-of-day signal control. The evaluation was performed under various traffic-demand conditions and included both isolated intersections and arterial sections. The analysis indicated a highly significant improvement with OPAC control. OPAC showed its best performance during oversaturated conditions. It reduced the travel time and number of stops by about 26 percent and 55 percent, respectively, for the entire arterial section. OPAC also improved traffic performance during changing demand conditions. It significantly improved the performance of an isolated intersection during undersaturated traffic conditions. OPAC reduced stopped delay on the major-street approach by 40 percent without affecting the minor-street performance.

This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations’ technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs’ decisions to adopt evidence-based clinical innovations such as buprenorphine use.

Background: Improved life functioning along with substance use reduction is increasingly recognized as the definition of effective addiction treatment. Objectives: To assess whether targeted health and social services contribute to improved physical/mental health and employment. Methods: This study used data from the National Treatment Improvement Evaluation Study (N = 3027) and modeled the improvement in physical/mental health and employment at discharge or 12 months after discharge compared with intake measures as a function of receipts of matched services. Results: Receiving matched medical service improves physical health only at treatment discharge; receiving matched mental health services improves mental health at discharge and 12 months after discharge; receiving matched vocational services improves employment only 12 months after discharge. Conclusions: Need‐service matching contributes to improved health and social outcomes when longitudinal assessments of treatment outcomes are used to evaluate treatment effectiveness. Scientific Significance: Study findings document the value of targeted services for achieving success in health and social functioning in comprehensive substance abuse treatment.

This study examines the impact of comprehensive services on posttreatment substance use among women with a history of intimate partner violence. The sample includes 1,123 women from 50 treatment facilities derived from the National Treatment Improvement Evaluation Study (NTIES). Generalized linear mixed modeling was used to determine whether a history of intimate partner violence moderates the association between service receipt and posttreatment substance use. Significant interactions were found between history of intimate partner violence and concrete ( p = .016) and family services ( p = .023) in predicting substance use.

a b s t r a c t Background: Culturally competent practice is broadly acknowledged to be an important strategy to increase the quality of services for racial/ethnic minorities in substance abuse treatment. However, few empirically derived measures of organizational cultural competence exist, and relatively little is known about how these measures affect treatment outcomes. Method: Using a nationally representative sample of outpatient substance abuse treatment (OSAT) programs, this study used item response theory to create two measures of cultural competence—organizational practices and managers' culturally sensitive beliefs—and examined their relationship to client wait time and retention using Poisson regression modeling. Results: The most common and precisely measured organizational practices reported by OSAT managers included matching providers and clients based on language/dialect; offering cross-cultural training; and fostering connections with community and faith-based organizations connected to racial and ethnic minority groups. The most culturally sensitive belief among OSAT managers was support for lan- guage/dialect matching for racial and ethnic minority clients. Results of regression modeling indicate that organizational practices were not related to either outcome. However, managers' culturally sensi- tive beliefs were negatively associated with average wait time (p < 0.05), and positively associated with average retention (p < 0.01). Conclusions: Managers' culturally sensitive beliefs—considered to be influential for effective implementa- tion of culturally competent practices—may be particularly relevant in influencing wait time and retention in OSAT organizations that treat Latinos and African American clients. © 2011 Elsevier Ireland Ltd. All rights reserved.