SUBSTANCE ABUSE TREATMENT NEEDS ASSESSMENT AND RESOURCE INVENTORY FOR PEOPLE LIVING WITH HIV DISEASE IN THE ATLANTA EMA

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1 SUBSTANCE ABUSE TREATMENT NEEDS ASSESSMENT AND RESOURCE INVENTORY FOR PEOPLE LIVING WITH HIV DISEASE IN THE ATLANTA EMA July, 2002 Prepared for: Fulton County Government Metropolitan Atlanta HIV Health Planning Council By: Center for Applied Research and Evaluation Studies Southeast AIDS Training and Education Center Department of Family and Preventive Medicine Emory University School of Medicine Consulting Provided By: Fred Marsteller, PhD Behavioral Research Consulting

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3 ACKNOWLEDGEMENTS This study would not have been possible without the input and assistance of substance abuse treatment and HIV care providers in the Atlanta Eligible Metropolitan Area (EMA). The Center for Applied Research and Evaluation Studies at the Southeast AIDS Training and Education Center, on behalf of Fulton County Government, would like to thank these organizations for their participation. This research study was made possible by a grant from Fulton County Government. Research team members included Debbie Isenberg, MPH, CHES, Linda Beer, PhD, Tracie Graham, MPH, Fred Marsteller, PhD, Fatema Salam, MPH, Shalini Eddens, MPH and Kathryn Tims. The key informant interview component received approval from the Emory University School of Medicine s Human Investigation Committee (reference HIC ).

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5 TABLE OF CONTENTS INTRODUCTION 1 SUBSTANCE ABUSE TREATMENT NEEDS ASSESSMENT Consumers 4 Ryan White Title I Providers 15 Substance Abuse Treatment Providers 22 Implications 30 SUBSTANCE ABUSE TREATMENT SERVICES RESOURCE INVENTORY Report Format - Substance Abuse Treatment Resource Inventory 35 Substance Abuse Treatment Resource Inventory Grid 40 APPENDICES A Substance Abuse Treatment Grid 2 A: 1 B Other Provided by Agency A: 17 C Admission Requirements by ASAM Level of Service A: 21 D Types of Admissions Accepted by Agency A: 26 E Accepted Pay Sources by Agency A: 32 F Agencies with Geographic Restrictions A: 38 G Required Medical Tests/Exams for Admission A: 39 H Survey Instrument A: 43 I Key Informant Interview Instrument A: 51 J Barrier Coding Guidelines A: 56

6 INTRODUCTION The Substance Abuse Treatment Needs Assessment and Resource Inventory for people living with HIV disease (PLWH) was conducted by the Center for Applied Research and Evaluation Studies at the Southeast AIDS Training and Education Center (SEATEC) on behalf of Fulton County Government and the Metropolitan Atlanta HIV Health Planning Council. Consulting services were provided to SEATEC by Fred Marsteller, Ph.D. of Behavioral Research Consulting. The purpose of this study was to address a concern expressed by the community of an unmet need for substance abuse treatment among PLWH in the Atlanta Eligible Metropolitan Area (EMA). The availability of substance abuse treatment services is a key part of comprehensive HIV care. The AIDS Epidemic and the Ryan White CARE Act reported that Substance abuse and addiction severely compromise an individual s ability to stay in care. Without substance abuse treatment, the chances of maintaining beneficial HIV treatment are reduced to almost zero. 1 The study design consisted of three components, which together created a comprehensive assessment of the issue of unmet need. The first component provides estimates of the substance abuse treatment needs of PLWH. The second component inventories existing substance abuse treatment services in the Atlanta EMA, focusing on the ability of these programs to serve the specific needs of PLWH. The final component synthesizes these findings regarding treatment need and available services in order to identify possible gaps in care. METHODOLOGY Data collection and analysis. In order to capture this information, three data sources were utilized. First, a secondary analysis of data from the Supplemental HIV/AIDS Surveillance (SHAS) study was used to estimate the substance abuse treatment needs for people living with AIDS (PLWA). Second, key informant interviews were conducted with Ryan White Title I providers to obtain their views on the substance abuse treatment needs of PLWH in the Atlanta EMA, 1 HIV/AIDS Bureau, Health Resources and Administration. The AIDS Epidemic and the Ryan White CARE Act: Past Progress, Future Challenges. U.S. Department of Health and Human 2000;5 1

7 including strengths, barriers to treatment and areas for expansion in the current system. Finally, a secondary analysis of a comprehensive HIV substance abuse treatment system assessment conducted by the Georgia Department of Human Resources, Division of Mental Health, Mental Retardation and Substance Abuse was completed in order to document the capacity of substance abuse treatment services in the Atlanta EMA, particularly to meet the needs of PLWH. Additional methodological information is available in each individual section of this report. Data considerations. The data presented in this study provide important information regarding the substance abuse treatment needs of PLWH in the Atlanta EMA, as well as the capacity of the existing system to address these needs. The report synthesizes data from various sources, allowing for a comprehensive assessment of whether gaps in substance abuse treatment exist. However, these data also have limitations that are important to understand when utilizing the information. One limitation of the SHAS data is that it is a self-report of addictive and sometimes illegal behavior. In addition, given the sensitivity of the information reported, it is possible that people with more problematic behavior may not have been interviewed. Finally, because the SHAS questionnaire was not specifically designed to identify substance abuse treatment need, a framework had to be created to estimate treatment need. Ideally, American Society of Addiction Medicine (ASAM) criteria would have been used to estimate levels of treatment need. However, because all six ASAM criteria were not available in the SHAS dataset, treatment need was estimated based on indications of substantial problem substance use and treatment history, using conservative criteria. 2 Therefore, because of the design of the SHAS study and the approach utilized in the analysis of the data, the information presented in the first section of this report is most likely a conservative estimate of substance abuse treatment need. Substance abuse treatment provider information is based on a sample of known ASAM level substance abuse treatment providers; capacity information therefore only includes those organizations that responded to the survey and provided an ASAM level of treatment. Organizations that provided only detoxification services and did not also provide ASAM treatment services were not included in this study. How to use this document. This report is divided into five sections, representing each of the three components of the study previously discussed. The first section, entitled Consumers, presents results from the secondary analysis of the SHAS data, including trends in alcohol and drug use and the probable treatment need of SHAS participants. The second section contains 2 These criteria are discussed in more detail in the Consumers section of this report. 2

8 results from Ryan White Title I key informant interviews, presenting providers perspectives about the substance abuse treatment needs of their clients, challenges in the current system and areas for expansion. The third section discusses results from the Substance Abuse Treatment Resource Inventory, including the current capacity of the system, the provision of specific HIV-related services and possible areas of expansion for capacity building. The fourth section presents the implications of this study, synthesizing all of this information in order to assess the current status of the substance abuse treatment system. Proposals for future steps to be taken to address the ongoing challenges of meeting the substance abuse treatment needs of PLWH are also included. The final section, the Resource Inventory, includes a listing of all ASAM substance abuse treatment services in the Atlanta EMA. Questions regarding this study should be directed to the project manager, Debbie Isenberg, MPH, CHES at

9 CONSUMERS The Supplemental HIV/AIDS Surveillance (SHAS) project, sponsored and conducted by the Centers for Disease Control and Prevention (CDC), Georgia Department of Human Resources (DHR) and Grady/Emory University, is a standardized one-hour structured interview of adults with an AIDS diagnosis that collects information regarding sexual and drug use behaviors, socioeconomic indicators, demographics, history of sexually transmitted diseases and barriers to care for medical and social services. Since 1990, the project in Georgia has primarily been conducted at the Infectious Disease Program of the Fulton DeKalb Hospital Authority/Grady Health System. Since 1995, a $10 incentive has been provided to participants. Informed consent is obtained from persons served at the facility, who then complete the interview, which is administered by trained interviewers. Data are entered into a local computer database and identifiers are removed. Data are then sent to DHR and CDC. In this report, only demographic and drug use behavior information from the SHAS dataset were used. S. Alan Fann, SHAS project manager, provided the requested information. The intent of this portion of the study was to analyze SHAS data to estimate potential treatment need using ASAM criteria. However, given that all six ASAM criteria were not available in the dataset, SEATEC used conservative criteria and estimated treatment need based on problematic substance use and client treatment history. Criteria for determining problematic use are discussed in each section. Given the broad application of these data to the estimation of treatment need, results should be interpreted cautiously. DEMOGRAPHICS This section describes the characteristics of PLWA interviewed in the SHAS project. To assess the representativeness of the participants, characteristics of persons interviewed are compared to those of people reported with AIDS (PWA) who were eligible for SHAS but not interviewed and with those of PWA who have been reported from the eight county area (Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnett, Newton, Rockdale, hereafter referred to as MSA). 4

10 Demographics of the sample Over the last ten years ( ), 2,298 individuals have been interviewed for the SHAS project. The majority of these participants were male (83%). Sixty-six percent were Black, 29% 60% 50% 40% 30% 20% 10% 0% SHAS Participants By Race and Gender Black White Hispanic Other Male Female were White, 3% were Hispanic and 2% were of other races. Participants were reported to the surveillance system with a primary HIV risk of men having sex with men (49%), injection drug use (24%) or heterosexual contact (15%). 3 Over half of the participants were years of age; 31% were and 10% were between the ages of Nearly 25% of participants had less than a high school education, 33% had a high school education or G.E.D. and 42% had completed college or graduate school. Most of the participants (79%) were unemployed at the time of the interview. Nearly half of the participants (49%) reported an annual income below $10,000. Representativeness of the sample The following table helps assess how well those interviewed in SHAS represent all cases within the MSA and how comparable participants are to non-participants. Overall, specific population characteristics between participants and non-participants are generally consistent. Slight differences in age between the groups may in part be due to differences in reporting criteria between the datasets. The MSA group reports the individual s age at diagnosis, while the interview participants and non-participants report the age at the time of the interview. The race and gender of SHAS participants in this report are also fairly consistent with PLWA in the Atlanta EMA by race and gender. 4 Therefore, the SHAS data appear to be a good source from which to estimate the needs of PLWH in the EMA as a whole. However, as with any data, this information should be used with caution. The SHAS participant data may not be representative of all individuals with HIV/AIDS in terms of other behaviors of interest, such as active engagement in substance use. Moreover, it is not possible to determine whether SHAS participants are 3 All AIDS cases are required to be reported to the Georgia Department of Human Resources which served as the source for these data. 4 The Atlanta EMA includes a 20-county geographic area. 5

11 representative of individuals living with HIV disease who have not been diagnosed with AIDS or of those receiving care in the MSA outside of the Grady system. GENDER, RACE 5, RISK GROUP AND AGE SAMPLE COMPARISONS* PLWA Participants (n=2,298) PWA Non-participants (n=1,516) 6 PWA in MSA 7 (n=14,469) Male 82.6% 84.9% 87.3% Female 17.3% 15.0% 12.7% Black, non-hispanic 66.3% 68.5% 58.5% White, non-hispanic 31.2% 28.9% 39.3% Other 2.4% 2.4% 2.2% Men Who Have Sex With Men 49.0% 46.9% 55.3% Men Who Have Sex With Men/Injecting Drug Users 9.5% 8.3% 6.0% Injecting Drug Users 24.3% 24.0% 18.8% Heterosexual Contact 14.7% 12.9% 9.9% Other 0.5% 0.7% 1.2% No Identified Risk 1.8% 6.9% 8.8% % 15.7% 19.4% % 50.6% 49.3% % 26.3% 23.5% Over % 7.2% 7.7% * Totals may not equal 100% due to rounding SUBSTANCE USE Four areas were assessed for problem substance use: alcohol use, crack use, poly-drug use and injecting drug use. Parameters for each area are discussed within each section. Indicators most likely to reflect problem use requiring treatment were used for this study. Data are not presented when the number of individuals in a particular category is less than five. No data for White females are presented in any of the substance use areas due to small sample sizes. Alcohol Participants were asked five questions regarding alcohol use. For the purposes of this study, problem alcohol use was defined as answering yes to the following two questions: 5 For racial and ethnic comparisons between participants and non-participants, the classification reported to DHR through routine surveillance activities is used here because self-reported data are unavailable on non-participants. 6 Eligible non-participants include persons that either refused the interview or could not be located within 24 months of having been reported to DHR. Ineligible non-participants include those deceased or medically unfit for an interview. 7 In this report, the Atlanta MSA is comprised of Cobb, Douglas, Fulton, Clayton, Gwinnett, Rockdale, Newton, and DeKalb counties. Cumulative case reports received at the health department among those persons with AIDS residing within these counties at the time of diagnosis are included. 6

12 Have you ever felt you ought to cut down on your drinking? Have you ever had a drink first thing in the morning to steady your nerves or rid yourself of a hangover? 8 Current Use In 1999, 19% (55/293) of all participants answered yes to both of these questions. Twentythree percent (36/160) of all Black males reported problem alcohol use in 1999, as compared to 18% (12/68) of all Black females and 10% (5/52) of all White males. Trends From , a total of 20% of all participants answered yes to both of these questions. Twentythree percent of all Blacks reported problem alcohol use, as compared to 13% of all White participants. There appears to be a slight decrease over time in the proportion of White male 50% 40% 30% 20% 10% 0% Problem Alcohol Use Among SHAS Participants, White Males Black Males Black Females participants reporting problem alcohol use, as compared to the varying levels among Black males and females. The trend among Black males and females may be evidence of a stabilization or decline in use but without additional data, it is difficult to ascertain. 9 Crack For the purposes of this study, problem crack use was defined as current use of crack, since no other indicator exists in the SHAS questionnaire, such as frequency of crack use. During the 8 These two questions are among the four that comprise the CAGE alcoholism screening scores. Any two answered yes are considered to be an indicator for potential alcoholism for CAGE. The two questions chosen were considered by the research team to most likely reflect problem use requiring treatment based on ASAM. The fifth question, In the past 5 years, did you drink any alcohol was a gateway question added to SHAS in The addition of a screening question in 1995 may have contributed to a decrease in individuals who reported problem alcohol use. Specifically, between all participants were asked the two questions that were used to assess problem alcohol use. Since 1995, only individuals who reported drinking alcohol in the last five years were asked these two questions. 7

13 interview, individuals were asked when they last used crack. Reported crack use in the month prior to the interview was used as an indicator of problem use that might require treatment. Current Use In 1999, 8% (22/293) of all participants reported problem crack use. Nine percent (15/160) of all Black males reported problem crack use in 1999, as compared to 7% (5/68) of all Black females. The number of White males and females reporting problem crack use was fewer than five, so these data are not reported. Trends From 1990 to 1999, a total of 8% of participants reported problem crack use. Eleven percent of all Black participants reported problem crack use during this time period (10% of males and 12% of females), as compared to 2% of all White participants. Given small sample sizes, trends were only examined for Blacks. There may be a slight decrease in the last five years in the proportion of Black males and females reporting problem crack use, but this is difficult to ascertain due to the limited time frame and small sample size. Moreover, while the proportion among Black females showed a continued decrease in 1999, the proportion of Black males showed an increase from 1998 to Continued monitoring of problem crack use among this population will help to assess any existing patterns or changing trends. 50% 40% 30% 20% 10% 0% Problem Crack Use Among SHAS Participants, Black Males Black Females Poly-Drug Use Participants were asked if they had taken non-injecting drugs in the past five years, and if so, they were asked what drugs they had used. For the purposes of this report, use of four or more drugs was considered problem poly-drug use that may require treatment. 8

14 Current Use In 1999, 8% (22/293) of all participants reported problem poly-drug use. Twenty-one percent of all White males (11/52) reported problem poly-drug use in 1999, as compared to six percent of all Black males (11/160). The number of participants reporting problem poly-drug use was fewer than five for both White and Black females, so these data could not be reported. Trends From 1990 to 1999, a total of 9% of participants reported problem poly-drug use. These data showed an opposite pattern of use among racial groups than that seen for problem crack use. In 50% 40% 30% 20% 10% 0% Problem Poly-Drug Use Among SHAS Participants, White Males Black Males this case, 17% of all Whites reported problem poly-drug use as compared to 6% of all Blacks. In addition, the participants who answered yes to this question were predominantly male, with 97% of Black problem polydrug users being male and 87% of White problem polydrug users being male. The proportion of Black males reporting problem poly-drug use appears to have remained relatively stable over the past seven years. The proportion among White males has shown variations that make it difficult to ascertain any trends for this population. Injecting Drug Use In The Last Six Months Participants were asked if they had injected drugs in the last six months, the most recent time frame available for analysis. Only 2% (36/2298) of all participants over the last ten years reported that they had injected drugs in the six months previous to the interview, and these were primarily males (92%). White males more frequently reported they had injected drugs in the previous six months than Black males (2.4% of White males versus 1.4% of Black males). Given the low frequency of respondents reporting that they had injected drugs in the last six months, no additional analysis was conducted. 9

15 POTENTIAL TREATMENT NEED For the purposes of this report, a potential treatment need was identified for all of those individuals who met the criteria for problematic substance use in any of the previously described areas. Individuals were identified as having a potential need for treatment if they reported any of the following behaviors: feeling like they ought to cut down on drinking and ever having had a drink first thing in the morning using crack within the past month using four or more non-injecting drugs in the past five years or; injecting drugs in the last six months Individuals with a potential need for treatment who reported no treatment history would, in practice, typically be assigned to outpatient treatment, while those identified as needing treatment and having a treatment history would more likely be assigned to residential treatment. Therefore the criteria for outpatient substance abuse treatment need is problematic substance use with no history of prior substance abuse treatment. The criteria for residential substance abuse treatment need is problem substance use with a history of prior substance abuse treatment. As previously mentioned, given that detoxification is a medical judgment, need for detoxification services could not be ascertained for this report. In addition, because there was not enough information in the SHAS questionnaire to differentiate between ASAM levels of treatment need, estimates of treatment need had to be consolidated. For the purposes of this report, outpatient treatment refers to ASAM level services I and II and residential services refer to ASAM level services III and IV. ASAM level criteria are: Level I treatment is typically a low intensity intervention extending beyond education Level II is more intensive outpatient treatment, which can be up to 8 hours/day Level III services are residential services designed for people with poor potential recovery involvement and provide services comparable to intensive outpatient services in a residential setting Level IV services are for medical complications due to addiction Current Need In 1999, 30% (88/293) of all participants potentially needed treatment based on the criteria previously discussed. Thirty-three percent of all Black males (53/160) potentially needed 10

16 treatment in 1999, as compared to 27% of White males (14/52) and 25% of Black females (17/68). Trends From 1990 to 1999, a total of 31% of participants potentially needed treatment. Thirty-three percent of all Blacks potentially needed treatment, as compared to 28% of all Whites. 60% 50% 40% 30% 20% 10% 0% Proportionally, the need for treatment was consistent among Black males and females (33% versus 32% respectively). The proportion of Black males potentially needing treatment has been consistent since Variations in the treatment need among Black females and White males make it much more difficult to ascertain trends. While it appears that there may be a decreasing trend among Black females and White males, it is difficult to ascertain trends without additional data. SHAS Participants Potentially Needing Treatment White Males Black Males Black Females Over the last ten years, the majority of potential treatment need was for outpatient services, based on the criteria used in this report. Moreover, the proportion of participants potentially needing outpatient services has increased over time, from 67% of all participants needing treatment in 1991 to 78% in The Patterns of Treatment Need, % 80% 60% 40% 20% 0% Residential Outpatient Source: SHAS respondents,

17 estimated proportion of residential versus outpatient substance abuse treatment need is comparable to that for the population as a whole. 10 The actual proportion of need among PLWH, however, may be substantially different from that estimated from these very limited data. Factors such as changes in substance use or barriers to treatment services could impact these estimates given that treatment history was a required criteria for residential treatment need. Without additional data, further interpretations cannot be made. Outpatient Treatment Current Need In 1999, 24% (69/293) of all participants potentially needed outpatient treatment. Twenty-five percent of all Black males (40/160) and White males (13/52) potentially needed outpatient treatment in 1999, as compared to 19% of Black females (13/68). Trends From 1991 to 1999, a total of 22% of participants potentially needed outpatient treatment. Proportionally, the need for outpatient treatment did not vary widely by race or gender; 24% of all Black females potentially needed outpatient treatment, compared to 23% of Black males and 22% 50% 40% 30% 20% 10% 0% SHAS Participants Potentially Needing Outpatient Treatment Need, White Males Black Males of White males. The proportion of those potentially needing outpatient treatment has fluctuated over the time period under study, making it difficult to ascertain any trends. 11 While it appears that outpatient treatment need among White males may be increasing in recent years, more data are needed before this trend can be verified. 10 Marsteller FA, Rolka D, Brogan D, Daniels D, Kroliiczak A, Chattopadhyay M. Georgia Telephone Household Survey of Substance Abuse Treatment Need. Unpublished report 1998; Findings for African American females are based on five years of data ( ) because the number of participants meeting the criteria was less than five for the prior years. 12

18 Residential Treatment Current Need In 1999, 7% (19/293) of all participants potentially needed residential treatment services. Eight percent of all Black males (13/160) potentially needed residential treatment in Given that fewer than five Black females or White males potentially needed residential treatment in 1999, these data were not analyzed. Trends From 1990 to 1999, a total of 9% of participants potentially needed residential treatment. Ten percent of all Black males potentially needed residential treatment, compared to 9% of all Black females and 7% of all White males. The proportion of White males potentially needing residential 50% 40% 30% 20% 10% 0% SHAS Participants Potentially Needing Residential Treatment, White Males Black Males treatment appears to be declining over time, although the most recent two years of data could not be included due to small sample sizes. The proportion among Black males has shown more fluctuations, making it more difficult to ascertain trends. While it appears that residential treatment need among Black males may be decreasing, more data are needed before this trend can be verified. Given the small number of Black females who potentially needed residential treatment over the last ten years, trend analysis could not be conducted. Treatment Barriers Only seven percent of individuals (164/2298) over the last ten years reported that they had tried to get into a treatment program within the five years previous to their interview but were unable to do so. Individuals who were unable to get into treatment were asked to identify the main reason that they could not get into a treatment program. The most frequently reported reason 13

19 was waiting list too long (66/164), followed by did not meet admission criteria (58/164) and money/financial (27/164). Most Frequently Reported Barriers To Treatment Among SHAS participants 50% 40% 30% 20% 10% Waiting list Admission criteria Money/financial Other 0% 14

20 RYAN WHITE TITLE I PROVIDERS Key informant interviews were requested with an agency-identified contact person at each of the Ryan White Title I funded agencies for FY Representatives at 22 agencies were contacted via letter requesting their participation in the study, with representatives from 18 agencies completing an interview within the designated time period. Each agency was asked to identify an individual within their agency who could address the issue of substance abuse treatment needs among PLWH in the Atlanta EMA. The majority of the questions asked were open-ended and were coded for presentation in this report. Providers were asked to provide their perception of their clients alcohol or drug problems including treatment needs, treatment barriers and capacity building needs. TREATMENT NEEDS Providers were asked how many clients they served in the last fiscal year and how many of these clients had alcohol or drug problems. They were then asked to assess if their clients have minor alcohol or drug problems or major alcohol or drug problems. Minor problems were defined as problems that occasionally interfered with a client s normal functioning and major problems were defined as problems that significantly interfered with a client s normal functioning. Major problems were further divided into problems that needed detoxification services and those that did not. After providers were given these standard definitions by the interviewer for major and minor problems, they were also asked to provide their own definitions. Very few of the providers consistently defined these problems. Inconsistencies were also evident when providers were asked how clients are assessed and referred to services. Specifically, only four providers used set criteria for assessment and referral, with three of these providers using the American Society of Addiction Medicine (ASAM) criteria for treatment placement, the basis for treatment services at the majority of publicly funded treatment centers in the Atlanta EMA. The other provider uses the addiction severity index. The implications of these inconsistencies are further examined in the implications section of this report. Cumulatively, Title I providers reported serving almost 18,000 clients in the last fiscal year. 12 They estimated that 67% (9,805 of the 14,688 clients for whom providers were able to assess 12 This number is based on self-report and not on Annual Administrative Report data. 15

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