Hefei Wen

The effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances

We estimate the effect of medical marijuana laws (MMLs) in ten states between 2004 and 2012 on adolescent and adult use of marijuana, alcohol, and other psychoactive substances. We find increases in the probability of current marijuana use, regular marijuana use and marijuana abuse/dependence among those aged 21 or above. We also find an increase in marijuana use initiation among those aged 12-20. For those aged 21 or above, MMLs further increase the frequency of binge drinking. MMLs have no discernible impact on drinking behavior for those aged 12-20, or the use of other psychoactive substances in either age group.

Race/Ethnicity and Geographic Access to Medicaid Substance Use Disorder Treatment Facilities in the United States

IMPORTANCE Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees. OBJECTIVE To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure. DESIGN, SETTING, AND PARTICIPANTS We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population. MAIN OUTCOMES AND MEASURES Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid. RESULTS Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME],  -3.1; 95% CI,  -5.2% to -0.9%), rural (-9.2%; -11.1% to -7.4%), and/or uninsured (-9.5%; -13.0% to -5.9%) residents are less likely to have one of these facilities. CONCLUSIONS AND RELEVANCE The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.

Improving Access to Mental Health Services for Youth in the United States

In the wake of the Connecticut school shooting, a public dialogue emerged about the accessibility of mental health (MH) care in the United States. Policy makers have called for a more critical examination of the MH treatment system, and advocates are rallying around federal legislation that would strengthen community-based MH services -- especially for children and adolescents.1 Although the implementation of recent federal policies (i.e., Mental Health Parity and Addiction Equity Act and the Affordable Care Act) will expand insurance coverage for MH disorders among many U.S. children, these expansions will not improve access if communities lack a sufficient infrastructure to serve those in need of care. Mental health facilities that provide outpatient specialty services for youth comprise a critical element of the treatment infrastructure for those with MH problems, especially for youth who are living in poverty, uninsured, and/or publicly insured. To inform the current dialogue, we present data from the 2008 National Survey of Mental Health Treatment Facilities (NSMHTF) and examine the extent to which gaps exist in this infrastructure. The NSMHTF is a national facility-level survey of entities that provide specialty MH services such as psychiatric hospitals, residential treatment centers, freestanding outpatient clinics/partial care facilities, and multiservice MH facilities.2 A response rate of 74% was achieved from the 13,068 facilities that were surveyed. Results from supplemental analyses restricting the sample of counties to those with complete facility-level data were similar to those presented below. Using these data, we examine the percentage of U.S. counties that have at least one outpatient MH facility offering: (1) services for children and adolescents; and (2) any specially designed programs to treat youth with the most severe MH problems (i.e., severe emotional disturbance). Only 63% of U.S. counties have a MH facility that provides outpatient treatment for children/adolescents, and fewer than half of U.S. counties have a MH facility with any special programs for youth with severe emotional disturbance. [Figure] These gaps in infrastructure are especially pronounced in rural communities; fewer than half of rural counties have a MH facility that provides outpatient treatment for children/adolescents and only one-third have an outpatient facility with special programs for youth with severe emotional disturbance. Figure 1 Percentage of U.S. Counties with Outpatient Facilities Providing MH Specialty Services to Youth These data likely represent conservative estimates of the extent of the problem because state funding for MH services has been reduced since 2008. Between 2009 and 2012, states eliminated more than

State Parity Laws and Access to Treatment for Substance Use Disorder in the United States Implications for Federal Parity Legislation

1.6 billion in general funds from their state MH agency budgets.3 These budgetary reductions have resulted in decreased services for children and adults with serious mental illness and closures of community MH programs, especially in states that have consistently reduced their budgets since 2009.3 These gaps in the MH facility infrastructure are part of a larger problem of geographic access to MH services for those with limited financial resources. Although some youth may seek treatment from MH clinicians in solo or small group practices, the accessibility of these services is limited for youth who are either uninsured or publically insured. For example, only 3% to 8% of patient caseloads for psychiatrists in solo or group practice, respectively, are covered by Medicaid.4 While services delivered through school-based MH programs could help address geographic and financial barriers to the MH care system, many school systems have also faced substantial budgetary reductions since the economic downturn;5 these budgetary reductions have affected the availability of school-based MH programs. Even if schools can offer MH services, they may lack the resources and personnel necessary to provide comprehensive services for youth with severe emotional disturbance for whom medication, intensive psychotherapy services, or both may be indicated. One option for addressing these gaps in geographic accessibility for low-income youth is to expand the capacity of primary care safety-net facilities such as federally qualified health centers (FQHCs) or rural health clinics (RHC) to provide youth MH services. Nearly three-fourths of counties have at least one of these clinics,6 most of which offer some type of MH services.7 Rural communities, in particular, may have the capacity to support these primary care facilities even if they do not have the capacity to support a specialty MH treatment facility. However, these primary care safety-net facilities typically care for patients with less severe MH disorders,7 suggesting that they may require additional resources to be able to provide comprehensive services to youth with the most severe MH problems. Telepsychiatry programs are one promising approach for providing specialty expertise for the treatment of complex patients in these primary care facilities. In addition to expanding the number of facilities that can provide MH services for children, efforts to improve access will also need to address the national shortage of MH providers – especially those who specialize in providing services to youth. The Health Resources and Services Administration has designated four-fifths of U.S. counties as partial or whole Mental Health Professional Shortage Areas.6 Policy makers should work to ensure there is an adequate workforce to serve this population through mechanisms such as supplementary training grants and loan forgiveness programs. The delivery system reforms considered above are necessary but not sufficient to ensure access to needed MH services for youth. Research has shown that knowledge, attitudes, beliefs, and stigma about MH problems and treatment greatly affect whether, when, and how youth access the treatment system.8 Many youth do not receive treatment for MH problems because they and/or their parents do not perceive a need for services, do not believe treatment will be helpful, or they are worried about what others will think if they receive treatment. Educational outreach efforts about MH problems and available treatment options are key tools for overcoming these gaps in knowledge and attitudes. School health curricula should be expanded to better address mental health problems and treatments. Although the implementation of recent federal policies expands insurance coverage for MH problems among many youth, the data presented above highlight large gaps in geographic access to a critical element of the MH infrastructure for youth with severe MH problems. These structural problems in access are compounded by ongoing shortages of MH providers, lack of knowledge about MH problems and available treatments, and stigma. The national dialogue that emerged from the Connecticut school shooting has provided an opportunity to address these challenges and achieve meaningful improvements in our children’s MH system. Improving access to MH services for this vulnerable population will require an ongoing national dialogue, sustained commitment from policy makers, and a comprehensive approach that addresses the complex array of barriers to treatment that exist in the current system.

Racial/Ethnic Differences in Treatment for Substance Use Disorders among U.S. Adolescents

IMPORTANCE The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment. OBJECTIVE To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation. DESIGN, SETTING, AND PARTICIPANTS We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment. INTERVENTIONS State-level SUD parity laws during the study period. MAIN OUTCOMES AND MEASURES State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance. RESULTS The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance. CONCLUSIONS AND RELEVANCE We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Geography and the Medicaid mental health care infrastructure: implications for health care reform.

OBJECTIVE This study examined differences in treatment rates for substance use disorders (SUD) among adolescents of white, black, Hispanic, Asian, Native American/Alaska Native, and Native Hawaiian/Pacific Islander race/ethnicity. METHOD Eight years of cross-sectional data (2001-2008) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 144,197 adolescents (aged 12-17 years); 12,634 adolescents were identified with SUD in the previous year. Weighted probit regressions were estimated with year fixed effects to examine whether racial/ethnic minorities had lower rates of treatment in any setting, in medical settings (i.e., hospital, rehabilitation facility, mental health clinic, and/or doctors office), and in self-help programs. Initial models controlled for demographics and health status. Additional models further adjusted for family income and health insurance status. RESULTS Among adolescents with SUD, unadjusted treatment rates ranged from 8.4% among blacks to 23.5% among Native Hawaiian/Pacific Islanders. After adjusting for demographics and health status, blacks (RD = -3.9%, 95% CI = -6.4%, -1.3%) and Hispanics (RD = -2.3%, 95% CI = -4.1%, -0.4%) were significantly less likely to receive SUD treatment than whites (adjusted treatment rate 10.7%). These differences were exacerbated after adjusting for family income and insurance status. Lower treatment rates for black and Hispanic adolescents persisted when examining SUD treatment rates in medical settings and self-help programs. Treatment rates for other racial/ethnic groups did not generally differ from whites. CONCLUSION Results highlight exceptionally low treatment rates for SUD among all adolescents, with blacks and Hispanics experiencing the lowest treatment rates across all racial/ethnic groups.

Impact of Medicaid Expansion on Medicaid-covered Utilization of Buprenorphine for Opioid Use Disorder Treatment

IMPORTANCE Medicaid is the largest payer of mental health (MH) care in the United States, and this role will increase among states that opt into the Medicaid expansion. However, owing to the dearth of MH care providers who accept Medicaid, expanded coverage may not increase access to services. Facilities that provide specialty outpatient MH services and accept Medicaid compose the backbone of the community-based treatment infrastructure for Medicaid enrollees. For states that opt into the expansion, it is important to understand which local communities may face the greatest barriers to access these facilities. OBJECTIVE To examine the availability of outpatient MH facilities that accept Medicaid across US counties and whether specific types of communities are more likely to lack this infrastructure. DESIGN, SETTING, AND PARTICIPANTS Data from the 2008 National Survey of Mental Health Treatment Facilities and Area Resource File were merged. A generalized ordered logistic regression with state fixed effects was estimated to examine determinants of accessibility of these facilities. Covariates included the percentages of residents who are black, Hispanic, living in poverty, and living in a rural area. MAIN OUTCOMES AND MEASURES An ordered variable assessed whether a county had no access to outpatient MH facilities that accept Medicaid, intermediate access to these facilities (ie, ≥1 facility, but not top quintile of facility to Medicaid enrollee per capita ratio), or high access (ie, top quintile of facility to Medicaid enrollee per capita ratio). RESULTS More than one-third of counties do not have any outpatient MH facilities that accept Medicaid. Communities with a larger percentage of residents who are black (marginal effect [ME] = 3.9%; 95% CI, 1.2%-6.6%), Hispanic (ME = 4.8%; 95% CI, 2.3%-7.4%), or living in a rural area (ME = 27.9%; 95% CI, 25.3%-30.4%) are more likely to lack these facilities. CONCLUSIONS AND RELEVANCE Many communities may face constraints on the MH safety-net system as Medicaid is expanded, especially rural communities and communities with a large percentage of black or Hispanic residents.

Depression and substance abuse and dependency in relation to current smoking status and frequency of smoking among nondaily and daily smokers.

Background: Buprenorphine has been proven effective in treating opioid use disorder. However, the high cost of buprenorphine and the limited prescribing capacity may restrict access to this effective medication-assisted treatment for opioid use disorder. Objective: To examine whether Medicaid expansion and physician prescribing capacity may have impacted buprenorphine utilization covered by Medicaid. Research Design: We used a quasi experimental difference-in-differences design to compare the pre-post changes in Medicaid-covered buprenorphine prescriptions and buprenorphine spending between the 26 states that implemented Medicaid expansions under the Affordable Care Act in 2014 and those that did not. Subjects: All Medicaid enrollees in the expansion states and the nonexpansion and late-expansion states. Measures: Quarterly Medicaid prescriptions for buprenorphine and spending on buprenorphine from the Centers for Medicare and Medicaid Services Medicaid Drug Utilization files 2011 to 2014. Results: State implementation of Medicaid expansions in 2014 was associated with a 70% increase (P<0.05) in Medicaid-covered buprenorphine prescriptions and a 50% increase (P<0.05) in buprenorphine spending. Physician prescribing capacity was also associated with increased buprenorphine utilization. Conclusions: Medicaid expansion has the potential to reduce the financial barriers to buprenorphine utilization and improve access to medication-assisted treatment of opioid use disorder. Active physician participation in the provision of buprenorphine is needed for ensuring that Medicaid expansion achieves its full potential in improving treatment access.

Health insurance coverage and the receipt of specialty treatment for substance use disorders among U.S. adults.

BACKGROUND AND OBJECTIVES Daily smoking rates are decreasing while intermittent or nondaily smoking rates are increasing. Little is known about the association of depression, alcohol abuse and dependence, and illicit drug abuse and dependence with different patterns of smoking, particularly nondaily smoking. Thus, we examined these relationships among current smokers versus nonsmokers and among those who smoke daily versus less frequently. METHODS We conducted a secondary analysis of 37,897 adults who participated in the 2008 National Survey on Drug Use and Health. We developed logistic regression models examining predictors of (i) current smoking and (ii) number of days smoking per month (1-10 days, 11-29 days, and ≥30 days) among current smokers, focusing on past-year major depression, alcohol abuse and dependence, and illicit drug abuse and dependence. RESULTS Compared to nonsmokers, current smokers more frequently reported a major depressive episode (p < .001), alcohol dependence (p < .001) and abuse (p < .001), and illicit drug dependence (p < .001) and abuse (p < .001), controlling for sociodemographics. Among current smokers, greater smoking frequency was associated with illicit drug dependence (p = .004), but lower likelihood of alcohol dependence (p = .01), alcohol abuse (p = .01), and illicit drug abuse (p = .01). CONCLUSIONS Although depression and substance use were associated with greater likelihood of smoking, most measures were inversely associated with frequency of smoking. Thus, it is important to examine underlying mechanisms contributing to these counterintuitive findings in order to inform intervention approaches. SCIENTIFIC SIGNIFICANCE With increased rates of nondaily smoking, developing a greater understanding about the mental health correlates related to this pattern of smoking is critical.

The Effect of Medical Marijuana Laws on Marijuana, Alcohol, and Hard Drug Use

OBJECTIVE The study examined the association between private health insurance and the receipt of specialty substance use disorder treatment. METHODS Weighted logistic regressions were estimated to examine the association between health insurance and the receipt of any specialty substance use disorder treatment in national samples of nonelderly adults with alcohol abuse or dependence (N=22,778), alcohol dependence (N=10,104), drug abuse or dependence (N=9,427), and drug dependence (N=6,736). Receipt of any specialty substance abuse treatment was compared among the uninsured and privately insured persons who reported known coverage, no coverage, or unknown coverage for alcohol and drug abuse treatment. Regressions adjusted for sociodemographic characteristics, treatment need, criminal justice involvement, and year of survey. RESULTS Compared with being uninsured, private insurance was associated with greater use of any specialty substance use disorder treatment only among those with alcohol dependence with known coverage for alcohol treatment (p<.05). CONCLUSIONS Private insurance was associated with increased use of specialty treatment among persons with severe alcohol use disorders who knew they had coverage for alcohol abuse treatment.