Barriers to Addiction Treatment Entry

By Dr. Adi Jaffe and Tariq Shaheed

How annoying is it to be running late for work unable to find your keys, wallet, or coveted smart phone? You check under the bed, between the sofa cushions, and in your useful phone valet, before giving up and calling in late to work (if it’s not your phone you’re missing). You ask your wife, who says she hasn’t seen it, and your child, who thinks it’s under the bed (you’ve looked, it’s not). Finally, giving up, you go to your car, where your phone sits smugly right on the passenger seat. As troubling and frequent as this story might be, it’s nothing compared to the difficult experience of over 20 million Americans who annually look for addiction treatment but don’t find it [2]. So what’s keeping so many Americans out of treatment?

Internal and external barriers to addiction treatment entry

Barriers to addiction treatment entry are plentyIn a study done in 2008, researchers surveyed a sample of 518 subjects varying in race and age, to find out about the barriers keeping them out of addiction treatment. [1] The study was conducted in Montgomery County Ohio, was a part of nationally funded “Drug Barrier Reduction” effort lead by the National Institute on Drug Abuse (NIDA). Most participants were using crack (38.4%), heroin (25.1%), marijuana (14.9%), and alcohol (11.2%). The researchers found a number of internal and external barriers that keep drug abusers from getting the help they need. Internal barriers included stigma, depression, personal beliefs, and attitudes about treatment, while external barriers (systematic or environmental circumstances that are out of a person’s control) include time conflicts, addiction treatment accessibility, entry difficulty, and cost of addiction treatment. [1]

The researchers concluded that both internal and external barriers can be addressed and improved, but that eliminating the external barriers to addiction treatment is most feasible and could substantially decrease the number of untreated addicts in the United States. Since addressing an internal barrier like “believing one can quit at anytime” (accounts for 29.3% untreated Americans) still requires the ability of the substance user to get treatment, it seems that addressing external triggers will be more immediately effective. Just as motivation to find an item such as keys, phone, or wallet is not the only factor in obtaining that item, a substance user with no internal barriers to treatment is still constrained by all those external barriers, and still not in substance abuse treatment.

The most commonly cited external barriers in the study were:

  1. Time conflicts – being unable to get off work for treatment, household obligations, busy schedules and simply not having time for substance abuse treatment.
  2. Treatment accessibility –  living too far away for treatment, not knowing where to go for treatment, having difficulty getting to and from treatment, and not understanding the addiction treatment options. Subjects reported that being wait-listed for a facility, and having to go through to many steps contributed to deterring them from seeking treatment.
  3. Financial barriers included inability to pay for treatment and being uninsured.

Some common internal barriers include:

  1. Stigma associated with the label of being call an alcoholic or an addict, or stigma regarding addiction treatment. Thus being unwilling to share problems and ask for help.
  2. Psychological distress such as depression and neuroticism which produces a lack of motivation among substance abuse treatment seekers.
  3. Personal beliefs
    1. Religion- God will remove the addiction at the right time
    2. Denial – User doesn’t believe they are an addict
    3. Doesn’t need treatment – For example 30% of heroin abuser believed they would recover without treatment.

Although getting substance abusers help is difficult, it starts by understanding the nature of the problem. While one person may not believe they are addicted, another may not understand how sliding scale payment for treatment works. Different individuals may need different helpful resources when it comes to understanding their options.

Thoughts and limitations regarding the research

As we pointed out in a recent article, it’s important to know who is participating in addiction research. In this case, the individuals recruited were reporting for substance abuse treatment assessment at a county intake center. This means the clients are likely from relatively low Socioeconomic Status (SES) groups, but also that they are for some reason motivated to find treatment. Those reasons themselves could be internal (decided to make a change) or external (got arrested), but it’s important to know that these findings do not necessarily apply to more affluent, insurance carrying, or addiction treatment uninterested, individuals. We are currently in the process of conducting a more general study to assess needs in that group.

Also, the time and costs constraints identified by participants can often be overcome by increasing flexibility in searches and by better tailoring the treatment referrals (see our Rehab Finder articles). Costs can be reduced while saving time by looking into outpatient, rather than residential, treatment options. Unfortunately, Americans have been exposed only to the residential treatment model (a la the Dr. Drew and Intervention television shows), but outpatient addiction treatment is effective, costs less, and truly a better fit for many clients (especially those still working, attending school, etc.).

Finally, not all of the internal beliefs can be written off as unreasonable barriers – indeed, it is likely that most individuals who do not seek official substance abuse treatment, and certainly most of those who never enter official substance abuse treatment, will still recover from their addiction without it. As we pointed out in previous articles (see here, and here), most people who use drugs do recover and many do it with no treatment per se, especially when looking at our biggest substance abuse problem – alcohol. That means that some people termed “in denial” and “not needing treatment” were actually either correct, lucky, or both. Recovery doesn’t have to look like we expect it to, it just has to result in a person who is no longer suffering with addiction.

A3 Plug (you knew it was coming)

At A3 we believe information is the key; by dispelling myths about addiction, removing stigma and anonymity, reviewing the latest research in treatment, and finding 21st century solutions to barriers, we hope to reduce the number of untreated. Join us in the fight to educate and treat addiction.

Citations:

1. Jiangmin Xua; Richard C. Rappa; Jichuan Wanga; Robert G. Carlsona. (2008) The Multidimensional Structure of External Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.
2. An investigation of stigma in individuals receiving treatment for substance abuse

More money more problems? Rich teens and drugs

Teens raised in affluent homes display the highest rates of depression, anxiety, and drug abuse according to a recent article in Monitor on Psychology, the APA‘s monthly magazine.

One of our recent posts dealt with some of the issues unique to teens and drugs. In addition to the issues we’d already mentioned, the article named a number of reasons for the high prevalence of mental-health issues among affluent teens. Among them were an increasingly narcissistic society, overbearing parents, and an common attitude of perfectionism.

Each of these reasons are likely contributors to the prevalence of mental health and drug abuse issues among upper-middle-class (and above) teens. Still, as far as I’m concerned, the main take home message of the article is this:

Money truly doesn’t buy happiness – Rich teens and drug use.

While drug abuse research often focuses on the lower socioeconomic strata these recent findings indicate that being financially stable offers little in the way of protection from some of the most common psychological difficulties.

Thankfully, the researchers cited in the article gave some simple advice to parents:

  • Give children clear responsibilities to help around the house.
  • Take part in community service (to unite the family and reduce narcissism).
  • Reduce TV watching (especially of reality TV shows that glorify celebrity and excess).
  • Monitor internet use.
  • Stop obsessing about perfect grades and focus instead on the joy of learning for its own sake.

I couldn’t agree more with these recommendations. Having taught a number of classes myself, I have witnessed the ridiculous inflation in students’ expectations of top grades. I think it’s time we turned attention back to the family and reintroduce some of the basic skills that many addicts find themselves learning much too late… Often in recovery.

Conversation with an addiction expert – Chris Evans, opiate master

Here at A3 we have already armed you with over 400 articles’ worth of knowledge on a wide variety of topics such as sex, gambling, and alcohol addictions. Our articles have in the past been written mostly by the team members at A3 (with a few notable guest pieces) based upon research findings and personal experience. Now we decided to expand our reach and get a different kind of perspective, broadening the knowledge we are able to provide to you and providing you expert opinion on commonly asked questions that the public often has about addiction.

Chris Evans, Ph.D.Our first expert is Christopher J. Evans (PhD) who is a professor in the David Geffen School of Medicine at UCLA. In addition to his work at the school of medicine, Evans is also a part of the UCLA Opioid Research Center, and Shirley and Stefan Hatos Center for Neuropharmacology. Evans is particularly interested in opioid drugs and is currently working on discovering the differential signaling at opioid receptors. Some of his past work has touched on withdrawal and on the theory of opponent processes involved in withdrawal, a counter to the theory that a rebound from over-activation is the whole story in the withdrawal process.

11 answers from an addiction expert

1 ) How did you become interested/specialized in addiction research?

Following my PhD studies in protein chemistry where I studied enkephalins and endorphins – opioids in our brains.

2 ) If you had to sum-up your “take” on substance use disorders in a few sentences, what would those be?

A sad disease where an obsession develops for an abused substance that creates fluctuating hedonic states. Increasingly there is decline to a negative hedonic state that can only be relieved by the abused drug.

3 ) What have been the most meaningful advances in the field in your view over the past decade?

The development of genetic models and imaging to begin to tease out circuits involved in liking a drug, withdrawal from a drug and drug craving.

4 ) What are the biggest barriers the field still needs to overcome?

Resolving the interaction of genetics and environment in creating phenotypes such as depression and anxiety leading to susceptibility to substance abuse.

5 ) What is your current research focused on?

Opioid drugs and the differential signaling at opioid receptors.

6 ) What do you hope to see get more research attention in the near future?

Inhalants and genetic studies aimed at behavioral phenotypes relevant to obsessive substance use .

7 ) How do you think the Health Care reform recently passed will affect addiction treatment?

It appears that there will be more attention paid to substance use disorders.  With increased access to health services the treatment of substance disorders is likely to become more of a focus.

8 ) What is your view regarding the inclusion of behavior/process addictions in the field?

They should be included.  Many of the process addictions have the same co-morbidities with substance use disorders and these are what need to be understood.

9 ) What is your view on the relative importance of Nature Vs. Nurture?

They are intertwined ? the interaction of nature with nurture directs our behaviors so neither should be considered more important than the other.  Either nature or nurture can be a disaster for a life.

10 ) In your view, what are some of the biggest misconceptions that the public still holds about addiction?

That addiction is driven solely by the acute rewarding effects of the drug and not by subsequent adaptations induced by the drug including dysphoria or memories of drug action.

11 ) What is the most common question you get from others (public?) when it comes to addiction?

Is marijuana harmful for you?

And there you go, a set of untouched, unedited answers about addiction and addiction research diretly from one of the masters. We hope you’ve enjoyed this and that you’ll look forward to more as All About Addiction continues a monthly exposure of what addiction research looks like from within.

About Addiction: Synthetic drugs, binge drinking, and recovery

You didn’t think we’d let you go a whole week without giving you another of our amazing updates about addiction news and research from around the globe did you? I’m sure you didn’t, and you were right! Here we are again with some good old discussions of marijuana, alcohol binge drinking, and other issues relevant to addiction and drug use. We hope you like it.

Synthetic Drugs and Marijuana

Greenbay Press Gazette– K2 is being sold and marketed as a legal substitute for marijuana and is also referred to as “Spice,” “Genie,” “Zohai” or simply “legal weed”. Apparently, cops in Wisconsin don’t like it too much and even though it hasn’t been banned in that state, they’re making trouble for those who sell it and store owners are complying by removing K2 products from their shelves.

Time– Another article examining the question “is marijuana addictive?” According the DSM, addiction is the compulsive use of a substance despite ongoing negative consequences, which may lead to tolerance or withdrawal symptoms when the substance is stopped. Although only about 10% of people who smoke marijuana become addicted to it by this definition, the real issue is how harmful the drug may be and what consequences it may produce for individuals who are using compulsively.

Science Daily– Speaking of negative impacts of marijuana use, this article discusses the possible neurobiological implications of marijuana and alcohol use during adolescence. Binge drinking in adolescence is a relatively common occurrence in many circles and it can detrimentally affect  cognitive functioning, especially in terms of attention and executive function.  Marijuana was found to, not surprisingly, leave adolescent users with impaired memory performance. The fact that this drug use is occurring during a sensitive developmental period likely doesn’t help.

ABC News– Kids aren’t the only ones who binge drink. Mothers who binge drink during pregnancy are increasing the chances that their babies will develop attention and memory deficits. It was estimated that about 40,000 infants are born each year with neurological and developmental damage that was caused by binge drinking. We’ve written about fetal alcohol syndrome in the past, and this piece touches on the same issues.

Addiction, recovery, and the good old drug trade

The Messenger– This article uses everyday language to explain the evolution of addiction and specifically seven signs that causal substance use is evolving into dependence. I can’t say I agree with everything said here, especially some of the statistics, but it’s a nice read, and as long as you recognize it for what it is – a very dumbed-down version of the real account of things – you’ll hopefully enjoy it!

Breaking the cycles– Sober Living Environments (SLEs)  is a term which is often spoken in  addiction/alcoholism treatment and recovery programs. Sober living houses provide recovering addicts with a drug-free environment in order to complete the transition from a residential treatment setting to stabilization and reintegration to a normal life.

Addiction Inbox– The UN has been monitoring designer drug trade. This report displays emerging trends in synthetic drug use. The drugs that are being observed are amphetamine-type stimulants, as well as designer drugs such as mephedrone, atypical synthetics like ketamine, synthetic opioids like fentanyl, and old standbys like LSD. The article gives a complete list of the findings of drugs used in a variety of countries and it is very fascinating.