The authors have declared that no competing interests exist.
‡ These authors are co-first authors on this work.
Access to adequate treatment for opioid use disorder (OUD) has been a high priority among American policymakers. Elucidation of the sociodemographic and institutional differences associated with the use, or lack thereof, of opioid agonist therapy (OAT) provides greater clarity on who receives OAT. Timely access to care is a further consideration and bears scrutiny as well.
We draw upon data from the Treatment Episode Data Set—Admissions (TEDS-A) to analyse the relationship between sociodemographic and institutional characteristics and the receipt of opioid agonist treatments and time waiting to enter treatment.
Estimates from logistic regression models highlight certain groups which show lower odds of receipt of OAT, including those in precarious housing arrangements, those unemployed or not otherwise in the labor force, and those referred by drug abuse care providers, educational institutions, employers, and the criminal justice system. Groups which showed higher odds of waiting over a week to enter treatment included those who were separated, divorced, or widowed, those working part-time, and those referred by drug abuse care providers, employers, and the criminal justice system.
Given the efficacy of OAT and the adverse outcomes associated with long waiting times, coordinated effort is needed to understand why these differences persist and how they may be addressed through appropriate policy responses.
In 2010 the global burden of disease attributable to opioid dependence was 9.2 million disability-adjusted life years (DALYs) with 15.5 million individuals suffering from opioid dependence and a significantly high burden of premature mortality affecting North America and Eastern Europe [
Our aim was to examine and identify patients with OUD in specialty addiction programs at risk of not receiving OAT as well as delayed entry to treatment based on: sociodemographic, and institutional characteristics. In this study, we draw upon the Treatment Episode Dataset (TEDS), an administrative dataset of annual admissions to substance abuse treatment facilities to analyse the differential use of OAT among admitted patients by patient characteristics as well as factors underlying time to enter treatment.
We used data from the Treatment Episode Data Set—Admissions (TEDS-A), a national administrative, fully anonymized dataset coordinated and maintained by the Center for Behavioral Health Statistics and Quality at the Substance Abuse and Mental Health Service Administration (SAMHSA), for admissions from 2014–17 [
Our analyses included all first-time admissions for opioid treatment where at least one of: heroin, non-prescription methadone, or other opiates was reported as the primary, secondary, or tertiary substance of abuse at time of admission (where TEDS-A only captures up to three substances of abuse at time of admission). Given our interest in the long-term treatment of OUDs with OATs vis-à-vis acute detoxification treatments, we excluded patients who were admitted only for detoxification treatment. As our outcome variables of interest were whether or not an admitted patient received opioid agonist therapy and time waiting to enter treatment, we excluded states which reported no patients receiving opioid agonist therapy (Georgia, Kansas, Montana, North Dakota, Oklahoma, Virginia, and West Virginia) or states missing data regarding time waiting to enter treatment (Connecticut, Georgia, Kentucky, Minnesota, New York, North Carolina, Oklahoma, Oregon, Rhode Island, Vermont, Virginia, Washington, and West Virginia) for each analysis, respectively, as these were likely to represent reporting errors or non-response for optional modules of TEDS-A. On This approach has been adopted elsewhere [
Our primary outcome variables were whether an admitted patient received OAT, coded as a dichotomous variable by SAMHSA; and days waiting to enter treatment, coded as an ordinal categorical variable by SAMHSA (i.e. no wait, within one week, within two weeks, within one month, and more than one month). For our analysis of time waiting to enter treatment, we further dichotomized time waiting to enter treatment as either: within one week or greater than one week. This interval was selected given the clinical importance of timely OAT initiation for patients experiencing physiological dependence arising from OUD [
Independent variables were categorized as sociodemographic or institutional. Demographic independent variables included age, sex, ethnicity, marital status, living arrangement, and veteran status. Socioeconomic variables included years of education, employment status, primary source of income, and health insurer. Institutional characteristics included service setting at time of admission and primary source of referral. These independent variables have been well-characterized in TEDS-A and used extensively in other comparable analyses [
In addition to variables already provided in TEDS-A, namely sociodemographic characteristics of admitted patients and institutional characteristics pertaining to admission, we coded for a dichotomous variable to indicate the reported use of alcohol or benzodiazepines on admission, both of which contraindicate the use of OAT for OUD [
All statistical analyses were performed in Stata 14 [
Descriptive sample characteristics are presented in Tables
Characteristic | Medication-Assisted Opioid Therapy | ||||
---|---|---|---|---|---|
No | Yes | Total | |||
No. | % | No. | % | ||
Age | |||||
18–20 | 15,850 | 82.1 | 3,446 | 17.9 | 19,296 |
21–24 | 49,224 | 75 | 16,399 | 25 | 65,623 |
25–29 | 76,169 | 69.2 | 33,939 | 30.8 | 110,108 |
30–34 | 56,587 | 65.4 | 29,960 | 34.6 | 86,547 |
35–39 | 35,327 | 62.5 | 21,199 | 37.5 | 56,526 |
40–44 | 20,810 | 58.1 | 14,998 | 41.9 | 35,808 |
45–49 | 16,546 | 51 | 15,915 | 49 | 32,461 |
50–54 | 12,848 | 45.9 | 15,165 | 54.1 | 28,013 |
55+ | 13,449 | 41.6 | 18,881 | 58.4 | 32,330 |
Total | 296,810 | 63.6 | 169,902 | 36.4 | 466,712 |
Sex | |||||
Male | 171,350 | 64.1 | 95,763 | 35.9 | 267,113 |
Female | 125,407 | 62.9 | 74,121 | 37.1 | 199,528 |
Total | 296,757 | 63.6 | 169,884 | 36.4 | 466,641 |
Ethnicity | |||||
White | 232,348 | 67.1 | 113,809 | 32.9 | 346,157 |
Black or African American | 31,093 | 51.3 | 29,525 | 48.7 | 60,618 |
Asian or Pacific Islander | 2,545 | 59.1 | 1,761 | 40.9 | 4,306 |
Native American | 5,408 | 72.7 | 2,032 | 27.3 | 7,440 |
Other | 19,613 | 57.1 | 14,753 | 42.9 | 34,366 |
Total | 291,007 | 64.3 | 161,880 | 35.7 | 452,887 |
Marital Status | |||||
Never Married | 161,768 | 66.2 | 82,587 | 33.8 | 244,355 |
Married | 35,931 | 64.1 | 20,163 | 35.9 | 56,094 |
Separated | 14,626 | 72.5 | 5,556 | 27.5 | 20,182 |
Divorced or Widowed | 29,048 | 68.3 | 13,510 | 31.7 | 42,558 |
Total | 241,373 | 66.5 | 121,816 | 33.5 | 363,189 |
Living Arrangement | |||||
Independent | 202,019 | 60.7 | 130,699 | 39.3 | 332,718 |
Dependent | 55,161 | 73.7 | 19,643 | 26.3 | 74,804 |
Homeless | 29,199 | 74.6 | 9,961 | 25.4 | 39,160 |
Total | 286,379 | 64.1 | 160,303 | 35.9 | 446,682 |
Veteran Status | |||||
No | 264,993 | 63.5 | 152,523 | 36.5 | 417,516 |
Yes | 5,934 | 63.4 | 3,430 | 36.6 | 9,364 |
Total | 270,927 | 63.5 | 155,953 | 36.5 | 426,880 |
Education | |||||
<8 Years | 13,790 | 64.6 | 7,567 | 35.4 | 21,357 |
9–11 Years | 60,295 | 63.9 | 34,096 | 36.1 | 94,391 |
12 Years | 140,093 | 64 | 78,825 | 36 | 218,918 |
13–15 Years | 57,293 | 71.6 | 22,716 | 28.4 | 80,009 |
16+ Years | 15,655 | 62.8 | 9,285 | 37.2 | 24,940 |
Total | 287,126 | 65.3 | 152,489 | 34.7 | 439,615 |
Employment Status | |||||
Full-Time | 43,621 | 61.6 | 27,175 | 38.4 | 70,796 |
Part-Time | 21,843 | 62.1 | 13,352 | 37.9 | 35,195 |
Unemployed | 132,192 | 69.8 | 57,303 | 30.2 | 189,495 |
Not in Labor Force | 94,569 | 61 | 60,381 | 39 | 154,950 |
Total | 292,225 | 64.9 | 158,211 | 35.1 | 450,436 |
Source Of Income/Support | |||||
Wages/Salary | 46,554 | 62.1 | 28,460 | 37.9 | 75,014 |
Public Assistance | 12,312 | 45.9 | 14,490 | 54.1 | 26,802 |
Retirement/Pension or Disability | 9,815 | 46.3 | 11,387 | 53.7 | 21,202 |
Other | 27,174 | 60.9 | 17,427 | 39.1 | 44,601 |
None | 68,862 | 79.9 | 17,310 | 20.1 | 86,172 |
Total | 164,717 | 64.9 | 89,074 | 35.1 | 253,791 |
Health Insurance | |||||
Private | 11,591 | 74.8 | 3,896 | 25.2 | 15,487 |
Medicaid | 53,938 | 45.6 | 64,462 | 54.4 | 118,400 |
Medicare or Other | 12,074 | 68.4 | 5,588 | 31.6 | 17,662 |
Uninsured | 53,543 | 82.9 | 11,060 | 17.1 | 64,603 |
Total | 131,146 | 60.7 | 85,006 | 39.3 | 216,152 |
Service Setting At Admission | |||||
Hospital | 1,735 | 93.1 | 129 | 6.9 | 1,864 |
Short-Term | 51,556 | 92.6 | 4,105 | 7.4 | 55,661 |
Long-Term | 30,844 | 93 | 2,329 | 7 | 33,173 |
Ambulatory, Intensive Outpatient | 54,297 | 88 | 7,387 | 12 | 61,684 |
Ambulatory, Non-Intensive Outpatient | 158,361 | 50.4 | 155,865 | 49.6 | 314,226 |
Total | 296,793 | 63.6 | 169,815 | 36.4 | 466,608 |
Principal Source Of Referral | |||||
Individual (including Self-Referral) | 110,118 | 45.8 | 130,248 | 54.2 | 240,366 |
Alcohol/Drug Abuse Care Provider | 22,933 | 72.4 | 8,750 | 27.6 | 31,683 |
Other Health Care Provider | 24,310 | 76.4 | 7,513 | 23.6 | 31,823 |
Educational Institution | 209 | 86.7 | 32 | 13.3 | 241 |
Employer | 1,167 | 92.2 | 99 | 7.8 | 1,266 |
Other Community Referral | 34,836 | 68.7 | 15,864 | 31.3 | 50,700 |
Court/Criminal Justice Referral/DUI | 96,218 | 93.8 | 6,356 | 6.2 | 102,574 |
Total | 289,791 | 63.2 | 168,862 | 36.8 | 458,653 |
Alcohol or Benzodiazepines Reported at Admission | |||||
No | 214,354 | 58.4 | 152,996 | 41.6 | 367,350 |
Yes | 82,456 | 83 | 16,906 | 17 | 99,362 |
Total | 296,810 | 63.6 | 169,902 | 36.4 | 466,712 |
Characteristic | Days Waiting to Enter Treatment | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
No wait | Within one week | Within two weeks | Within one month | More than one month | Total | ||||||
No. | % | No. | % | No. | % | No. | % | No. | % | ||
Age | |||||||||||
18–20 | 8,236 | 68.2 | 2,551 | 21.1 | 627 | 5.2 | 482 | 4 | 172 | 1.4 | 12,068 |
21–24 | 29,803 | 70.7 | 8,067 | 19.1 | 2,119 | 5 | 1,631 | 3.9 | 516 | 1.2 | 42,136 |
25–29 | 53,751 | 72.9 | 12,964 | 17.6 | 3,422 | 4.6 | 2,589 | 3.5 | 1,009 | 1.4 | 73,735 |
30–34 | 42,989 | 73.7 | 10,138 | 17.4 | 2,478 | 4.2 | 1,966 | 3.4 | 736 | 1.3 | 58,307 |
35–39 | 28,480 | 74.5 | 6,355 | 16.6 | 1,655 | 4.3 | 1,247 | 3.3 | 510 | 1.3 | 38,247 |
40–44 | 18,507 | 75.7 | 4,103 | 16.8 | 893 | 3.7 | 681 | 2.8 | 262 | 1.1 | 24,446 |
45–49 | 18,219 | 78.1 | 3,509 | 15 | 815 | 3.5 | 593 | 2.5 | 196 | 0.8 | 23,332 |
50–54 | 16,535 | 79.8 | 3,000 | 14.5 | 586 | 2.8 | 461 | 2.2 | 150 | 0.7 | 20,732 |
55+ | 20,012 | 81.9 | 3,097 | 12.7 | 637 | 2.6 | 495 | 2 | 193 | 0.8 | 24,434 |
Total | 236,532 | 74.5 | 53,784 | 16.9 | 13,232 | 4.2 | 10,145 | 3.2 | 3,744 | 1.2 | 317,437 |
Sex | |||||||||||
Male | 134,703 | 74.4 | 30,936 | 17.1 | 7,460 | 4.1 | 5,838 | 3.2 | 2,179 | 1.2 | 181,116 |
Female | 101,799 | 74.7 | 22,840 | 16.8 | 5,767 | 4.2 | 4,304 | 3.2 | 1,564 | 1.1 | 136,274 |
Total | 236,502 | 74.5 | 53,776 | 16.9 | 13,227 | 4.2 | 10,142 | 3.2 | 3,743 | 1.2 | 317,390 |
Race | |||||||||||
White | 166,028 | 72.6 | 41,247 | 18 | 10,417 | 4.6 | 8,071 | 3.5 | 2,978 | 1.3 | 228,741 |
Black or African American | 38,506 | 79.7 | 7,103 | 14.7 | 1,461 | 3 | 986 | 2 | 265 | 0.5 | 48,321 |
Asian or Pacific Islander | 2,445 | 73.9 | 603 | 18.2 | 107 | 3.2 | 114 | 3.4 | 38 | 1.1 | 3,307 |
Native American | 2,508 | 74.6 | 507 | 15.1 | 148 | 4.4 | 130 | 3.9 | 70 | 2.1 | 3,363 |
Other | 16,070 | 75.7 | 3,225 | 15.2 | 902 | 4.2 | 697 | 3.3 | 333 | 1.6 | 21,227 |
Total | 225,557 | 74 | 52,685 | 17.3 | 13,035 | 4.3 | 9,998 | 3.3 | 3,684 | 1.2 | 304,959 |
Marital Status | |||||||||||
Never Married | 115,434 | 71.2 | 32,037 | 19.8 | 7,498 | 4.6 | 5,479 | 3.4 | 1,729 | 1.1 | 162,177 |
Married | 22,734 | 70.5 | 6,420 | 19.9 | 1,563 | 4.8 | 1,131 | 3.5 | 379 | 1.2 | 32,227 |
Separated | 8,620 | 70 | 2,361 | 19.2 | 658 | 5.3 | 504 | 4.1 | 169 | 1.4 | 12,312 |
Divorced or Widowed | 18,364 | 69.3 | 5,399 | 20.4 | 1,383 | 5.2 | 1,002 | 3.8 | 338 | 1.3 | 26,486 |
Total | 165,152 | 70.8 | 46,217 | 19.8 | 11,102 | 4.8 | 8,116 | 3.5 | 2,615 | 1.1 | 233,202 |
Living Arrangement | |||||||||||
Independent | 158,464 | 73.8 | 38,170 | 17.8 | 9,192 | 4.3 | 6,645 | 3.1 | 2,336 | 1.1 | 214,807 |
Dependent | 44,128 | 74.8 | 9,312 | 15.8 | 2,445 | 4.1 | 2,193 | 3.7 | 890 | 1.5 | 58,968 |
Homeless | 20,257 | 71.5 | 5,114 | 18.1 | 1,393 | 4.9 | 1,121 | 4 | 446 | 1.6 | 28,331 |
Total | 222,849 | 73.8 | 52,596 | 17.4 | 13,030 | 4.3 | 9,959 | 3.3 | 3,672 | 1.2 | 302,106 |
Veteran Status | |||||||||||
No | 213,260 | 73.8 | 50,307 | 17.4 | 12,538 | 4.3 | 9,446 | 3.3 | 3,421 | 1.2 | 288,972 |
Yes | 4,869 | 71.6 | 1,317 | 19.4 | 278 | 4.1 | 253 | 3.7 | 88 | 1.3 | 6,805 |
Total | 218,129 | 73.7 | 51,624 | 17.5 | 12,816 | 4.3 | 9,699 | 3.3 | 3,509 | 1.2 | 295,777 |
Education | |||||||||||
<8 Years | 9,325 | 73.8 | 2,256 | 17.9 | 496 | 3.9 | 409 | 3.2 | 146 | 1.2 | 12,632 |
9–11 Years | 48,243 | 74.2 | 10,996 | 16.9 | 2,730 | 4.2 | 2,249 | 3.5 | 805 | 1.2 | 65,023 |
12 Years | 112,701 | 73.5 | 27,332 | 17.8 | 6,603 | 4.3 | 4,925 | 3.2 | 1,829 | 1.2 | 153,390 |
13–15 Years | 32,722 | 69.3 | 9,233 | 19.6 | 2,546 | 5.4 | 1,942 | 4.1 | 775 | 1.6 | 47,218 |
16+ Years | 12,214 | 76.3 | 2,536 | 15.8 | 660 | 4.1 | 459 | 2.9 | 140 | 0.9 | 16,009 |
Total | 215,205 | 73.1 | 52,353 | 17.8 | 13,035 | 4.4 | 9,984 | 3.4 | 3,695 | 1.3 | 294,272 |
Employment Status | |||||||||||
Full-Time | 31,458 | 72.4 | 8,137 | 18.7 | 1,964 | 4.5 | 1,375 | 3.2 | 518 | 1.2 | 43,452 |
Part-Time | 16,544 | 72.3 | 4,074 | 17.8 | 1,174 | 5.1 | 788 | 3.4 | 297 | 1.3 | 22,877 |
Unemployed | 89,931 | 72 | 22,929 | 18.4 | 5,956 | 4.8 | 4,471 | 3.6 | 1,588 | 1.3 | 124,875 |
Not in Labor Force | 85,056 | 76.2 | 17,899 | 16 | 4,017 | 3.6 | 3,378 | 3 | 1,272 | 1.1 | 111,622 |
Total | 222,989 | 73.6 | 53,039 | 17.5 | 13,111 | 4.3 | 10,012 | 3.3 | 3,675 | 1.2 | 302,826 |
Source Of Income/Support | |||||||||||
Wages/Salary | 38,861 | 71.4 | 10,421 | 19.1 | 2,612 | 4.8 | 1,894 | 3.5 | 647 | 1.2 | 54,435 |
Public Assistance | 15,807 | 77 | 3,352 | 16.3 | 666 | 3.2 | 529 | 2.6 | 167 | 0.8 | 20,521 |
Retirement/Pension or Disability | 13,882 | 76.7 | 2,996 | 16.6 | 577 | 3.2 | 475 | 2.6 | 167 | 0.9 | 18,097 |
Other | 17,382 | 74.1 | 4,498 | 19.2 | 820 | 3.5 | 582 | 2.5 | 164 | 0.7 | 23,446 |
None | 42,976 | 66.3 | 14,550 | 22.5 | 3,320 | 5.1 | 2,930 | 4.5 | 1,013 | 1.6 | 64,789 |
Total | 128,908 | 71.1 | 35,817 | 19.8 | 7,995 | 4.4 | 6,410 | 3.5 | 2,158 | 1.2 | 181,288 |
Health Insurance | |||||||||||
Private | 8,586 | 61.1 | 4,105 | 29.2 | 735 | 5.2 | 485 | 3.5 | 140 | 1 | 14,051 |
Medicaid | 85,714 | 80.1 | 15,646 | 14.6 | 2,804 | 2.6 | 2,234 | 2.1 | 632 | 0.6 | 107,030 |
Medicare or Other | 10,251 | 73.8 | 2,445 | 17.6 | 552 | 4 | 466 | 3.4 | 167 | 1.2 | 13,881 |
Uninsured | 40,396 | 69.2 | 12,134 | 20.8 | 2,861 | 4.9 | 2,313 | 4 | 708 | 1.2 | 58,412 |
Total | 144,947 | 75 | 34,330 | 17.8 | 6,952 | 3.6 | 5,498 | 2.8 | 1,647 | 0.9 | 193,374 |
Service Setting At Admission | |||||||||||
Hospital | 85 | 26.6 | 122 | 38.2 | 42 | 13.2 | 50 | 15.7 | 20 | 6.3 | 319 |
Short-Term | 22,173 | 64.7 | 7,710 | 22.5 | 2,234 | 6.5 | 1,717 | 5 | 462 | 1.3 | 34,296 |
Long-Term | 14,419 | 59 | 5,772 | 23.6 | 1,634 | 6.7 | 1,760 | 7.2 | 856 | 3.5 | 24,441 |
Ambulatory, Intensive Outpatient | 33,292 | 68.2 | 11,170 | 22.9 | 2,307 | 4.7 | 1,583 | 3.2 | 433 | 0.9 | 48,785 |
Ambulatory, Non-Intensive Outpatient | 166,537 | 79.5 | 29,007 | 13.8 | 7,014 | 3.3 | 5,035 | 2.4 | 1,973 | 0.9 | 209,566 |
Total | 236,506 | 74.5 | 53,781 | 16.9 | 13,231 | 4.2 | 10,145 | 3.2 | 3,744 | 1.2 | 317,407 |
Principal Source Of Referral | |||||||||||
Individual (including Self-Referral) | 132,257 | 78.3 | 25,967 | 15.4 | 5,390 | 3.2 | 3,830 | 2.3 | 1,387 | 0.8 | 168,831 |
Alcohol/Drug Abuse Care Provider | 14,981 | 65.5 | 5,328 | 23.3 | 1,411 | 6.2 | 977 | 4.3 | 179 | 0.8 | 22,876 |
Other Health Care Provider | 11,028 | 70 | 3,248 | 20.6 | 729 | 4.6 | 532 | 3.4 | 209 | 1.3 | 15,746 |
Educational Institution | 87 | 68.5 | 26 | 20.5 | 7 | 5.5 | 4 | 3.1 | 3 | 2.4 | 127 |
Employer | 266 | 65.8 | 94 | 23.3 | 27 | 6.7 | 17 | 4.2 | 0 | 0 | 404 |
Other Community Referral | 26,036 | 75.1 | 5,837 | 16.8 | 1,464 | 4.2 | 1,046 | 3 | 301 | 0.9 | 34,684 |
Court/Criminal Justice Referral/DUI | 47,123 | 68.3 | 12,744 | 18.5 | 4,001 | 5.8 | 3,570 | 5.2 | 1,541 | 2.2 | 68,979 |
Total | 231,778 | 74.4 | 53,244 | 17.1 | 13,029 | 4.2 | 9,976 | 3.2 | 3,620 | 1.2 | 311,647 |
Alcohol or Benzodiazepines Reported at Admission | |||||||||||
Substance Not Reported | 199,639 | 76.2 | 41,930 | 16 | 9,856 | 3.8 | 7,641 | 2.9 | 2,861 | 1.1 | 261,927 |
Substance Reported | 36,893 | 66.5 | 11,854 | 21.4 | 3,376 | 6.1 | 2,504 | 4.5 | 883 | 1.6 | 55,510 |
Total | 236,532 | 74.5 | 53,784 | 16.9 | 13,232 | 4.2 | 10,145 | 3.2 | 3,744 | 1.2 | 317,437 |
The unadjusted and adjusted results of logistic regression of patient and institutional characteristics on receipt of OAT are shown in
Characteristic | Unadjusted | Adjusted |
||
---|---|---|---|---|
OR | 95% CI | AOR | 95% CI | |
Age | ||||
18–20 | 1 | 1 | ||
21–24 | 1.532 | (1.471–1.596) | 1.527 | (1.377–1.693) |
25–29 | 2.049 | (1.971–2.131) | 1.780 | (1.612–1.966) |
30–34 | 2.435 | (2.341–2.533) | 2.083 | (1.884–2.304) |
35–39 | 2.760 | (2.650–2.874) | 2.365 | (2.130–2.625) |
40–44 | 3.315 | (3.177–3.459) | 2.706 | (2.426–3.018) |
45–49 | 4.424 | (4.239–4.618) | 3.023 | (2.706–3.378) |
50–54 | 5.429 | (5.197–5.672) | 3.024 | (2.698–3.390) |
55+ | 6.457 | (6.186–6.741) | 3.444 | (3.068–3.865) |
Female | 1.058 | (1.045–1.070) | 1.113 | (1.076–1.151) |
Ethnicity | ||||
White | 1 | 1 | ||
Black or African American | 1.939 | (1.905–1.973) | 0.987 | (0.941–1.035) |
Asian or Pacific Islander | 1.413 | (1.329–1.502) | 0.882 | (0.733–1.060) |
Native American | 0.767 | (0.729–0.808) | 1.355 | (1.122–1.637) |
Other | 1.536 | (1.501–1.571) | 0.822 | (0.734–0.920) |
Marital Status | ||||
Never Married | 1 | 1 | ||
Married | 1.099 | (1.078–1.120) | 0.938 | (0.896–0.982) |
Separated | 0.744 | (0.721–0.768) | 0.835 | (0.778–0.897) |
Divorced or Widowed | 0.911 | (0.891–0.931) | 0.813 | (0.772–0.857) |
Living Arrangement | ||||
Independent | 1 | 1 | ||
Dependent | 0.550 | (0.541–0.560) | 0.706 | (0.670–0.745) |
Homeless | 0.527 | (0.515–0.540) | 0.731 | (0.681–0.784) |
Veteran Status | 1.004 | (0.962–1.048) | 1.100 | (0.988–1.224) |
Years of Education | ||||
<8 Years | 1 | 1 | ||
9–11 Years | 1.031 | (0.999–1.063) | 1.185 | (1.099–1.278) |
12 Years | 1.025 | (0.996–1.056) | 1.061 | (0.989–1.138) |
13–15 Years | 0.723 | (0.700–0.746) | 0.956 | (0.882–1.035) |
16+ Years | 1.081 | (1.041–1.123) | 0.905 | (0.826–0.992) |
Employment Status | ||||
Full-Time | 1 | 1 | ||
Part-Time | 0.981 | (0.956–1.007) | 0.974 | (0.915–1.036) |
Unemployed | 0.696 | (0.683–0.708) | 0.868 | (0.812–0.928) |
Not in Labor Force | 1.025 | (1.006–1.044) | 0.770 | (0.717–0.827) |
Primary Source of Income | ||||
Wages/Salary | 1 | 1 | ||
Public Assistance | 1.925 | (1.872–1.980) | 1.265 | (1.175–1.361) |
Retirement/Pension or Disability | 1.898 | (1.840–1.957) | 1.241 | (1.147–1.343) |
Other | 1.049 | (1.024–1.075) | 0.989 | (0.923–1.059) |
None | 0.411 | (0.402–0.420) | 0.991 | (0.928–1.059) |
Health Insurer | ||||
Private | 1 | 1 | ||
Medicaid | 3.556 | (3.423–3.694) | 1.676 | (1.579–1.779) |
Medicare or Other | 1.377 | (1.312–1.445) | 1.348 | (1.242–1.464) |
Uninsured | 0.615 | (0.589–0.641) | 1.049 | (0.986–1.116) |
Service Setting at Time of Admission | ||||
Hospital | 1 | 1 | ||
Short-Term | 1.071 | (0.893–1.284) | 4.455 | (1.076–18.45) |
Long-Term | 1.016 | (0.845–1.220) | 3.986 | (0.960–16.56) |
Ambulatory, Intensive Outpatient | 1.830 | (1.528–2.192) | 5.420 | (1.310–22.42) |
Ambulatory, Non-Intensive Outpatient | 13.24 | (11.07–15.83) | 37.69 | (9.116–155.9) |
Primary Source of Referral | ||||
Individual (including Self-Referral) | 1 | 1 | ||
Alcohol/Drug Abuse Care Provider | 0.323 | (0.314–0.331) | 0.437 | (0.410–0.467) |
Other Health Care Provider | 0.261 | (0.254–0.268) | 0.512 | (0.482–0.543) |
Educational Institution | 0.129 | (0.0892–0.188) | 0.114 | (0.0438–0.294) |
Employer | 0.0717 | (0.0584–0.0881) | 0.101 | (0.0636–0.159) |
Other Community Referral | 0.385 | (0.377–0.393) | 0.253 | (0.241–0.266) |
Court/Criminal Justice Referral/DUI | 0.0558 | (0.0544–0.0574) | 0.0686 | (0.0651–0.0724) |
Alcohol or Benzodiazepines Reported at Admission | 0.287 | (0.282–0.292) | 0.464 | (0.445–0.484) |
*Adjusted for year, state, age, sex, ethnicity, marital status, living arrangement, veteran status, years of education, employment status, primary source of income, health insurer, census division, service setting at time of admission, primary source of referral, and alcohol/benzodiazepine report at admission.
We found that the odds of receipt of OAT were higher in all age groups relative to the reference group (aged 18–20) with the highest odds of receipt of OAT reported by those in age groups 45–49, 50–54, and 55+. Women showed very slightly higher odds of receipt of OAT compared to men. Native Americans showed higher odds of receipt of OAT compared to White Americans while those reporting Other as ethnicity showed lower odds. Compared to those reporting never having married, all other groups showed lower odds of receipt of OAT. Those reporting a dependent or homeless living situation showed lower odds of receipt of OAT compared to those who reported an independent living situation. There was no statistically significant difference in the odds of receipt of OAT between veterans and non-veterans. Compared to those working full-time, those who were unemployed or otherwise not in the labor force exhibited lower odds of receipt of OAT. Those insured by either Medicaid or Medicare showed higher odds of receipt of OAT.
Those admitted to short-term care facilities or an ambulatory care setting showed statistically significantly higher odds of receipt of OAT compared to those admitted to the hospital setting. All primary sources of referral showed lower odds of receipt of OAT compared with the reference group of individually referred (including self-referred) patients.
The unadjusted and adjusted results of logistic regression of patient and institutional characteristics on time waiting to enter treatment (i.e. one week or less compared to more than one week) are shown in
Characteristic | Unadjusted | Adjusted |
||
---|---|---|---|---|
OR | 95% CI | AOR | 95% CI | |
Age | ||||
18–20 | 1 | 1 | ||
21–24 | 0.949 | (0.888–1.013) | 1.047 | (0.941–1.165) |
25–29 | 0.886 | (0.832–0.944) | 1.119 | (1.009–1.241) |
30–34 | 0.821 | (0.770–0.876) | 1.077 | (0.968–1.198) |
35–39 | 0.825 | (0.771–0.883) | 1.080 | (0.965–1.210) |
40–44 | 0.684 | (0.634–0.737) | 0.966 | (0.854–1.093) |
45–49 | 0.622 | (0.576–0.671) | 1.069 | (0.942–1.213) |
50–54 | 0.516 | (0.475–0.560) | 0.954 | (0.834–1.092) |
55+ | 0.483 | (0.446–0.523) | 0.889 | (0.773–1.022) |
Female | 0.999 | (0.974–1.024) | 1.010 | (0.968–1.055) |
Ethnicity | ||||
White | 1 | 1 | ||
Black or African American | 0.574 | (0.551–0.598) | 0.886 | (0.833–0.943) |
Asian or Pacific Islander | 0.821 | (0.722–0.932) | 0.924 | (0.753–1.134) |
Native American | 1.115 | (0.997–1.246) | 0.977 | (0.807–1.183) |
Other | 0.967 | (0.921–1.015) | 0.980 | (0.861–1.114) |
Marital Status | ||||
Never Married | 1 | 1 | ||
Married | 1.057 | (1.015–1.101) | 1.030 | (0.968–1.096) |
Separated | 1.215 | (1.145–1.290) | 1.156 | (1.058–1.264) |
Divorced or Widowed | 1.149 | (1.101–1.200) | 1.137 | (1.063–1.216) |
Living Arrangement | ||||
Independent | 1 | 1 | ||
Dependent | 1.119 | (1.084–1.155) | 0.933 | (0.883–0.986) |
Homeless | 1.262 | (1.212–1.315) | 0.892 | (0.823–0.967) |
Veteran Status | 1.038 | (0.955–1.129) | 0.910 | (0.798–1.037) |
Years of Education | ||||
<8 Years | 1 | 1 | ||
9–11 Years | 1.076 | (1.004–1.152) | 1.115 | (1.003–1.238) |
12 Years | 1.051 | (0.984–1.122) | 1.069 | (0.968–1.181) |
13–15 Years | 1.382 | (1.290–1.482) | 1.103 | (0.991–1.227) |
16+ Years | ||||
Employment Status | ||||
Full-Time | 1 | 1 | ||
Part-Time | 1.125 | (1.065–1.188) | 1.209 | (1.114–1.313) |
Unemployed | 1.093 | (1.052–1.135) | 1.060 | (0.970–1.158) |
Not in Labor Force | 0.864 | (0.831–0.899) | 1.019 | (0.928–1.119) |
Primary Source of Income | ||||
Wages/Salary | 1 | 1 | ||
Public Assistance | 0.680 | (0.639–0.723) | 0.956 | (0.863–1.059) |
Retirement/Pension or Disability | 0.691 | (0.647–0.737) | 0.978 | (0.876–1.093) |
Other | 0.684 | (0.645–0.726) | 0.966 | (0.878–1.062) |
None | 1.207 | (1.163–1.254) | 0.894 | (0.823–0.970) |
Health Insurer | ||||
Private | 1 | 1 | ||
Medicaid | 0.522 | (0.491–0.555) | 0.914 | (0.846–0.987) |
Medicare or Other | 0.871 | (0.803–0.945) | 0.975 | (0.881–1.080) |
Uninsured | 1.045 | (0.982–1.112) | 0.964 | (0.894–1.039) |
Service Setting at Time of Admission | ||||
Hospital | 1 | 1 | ||
Short-Term | 0.273 | (0.216–0.344) | 0.382 | (0.284–0.514) |
Long-Term | 0.389 | (0.308–0.491) | 0.547 | (0.405–0.740) |
Ambulatory, Intensive Outpatient | 0.180 | (0.142–0.227) | 0.221 | (0.164–0.297) |
Ambulatory, Non-Intensive Outpatient | 0.133 | (0.105–0.167) | 0.243 | (0.181–0.326) |
Primary Source of Referral | ||||
Individual (including Self-Referral) | 1 | 1 | ||
Alcohol/Drug Abuse Care Provider | 1.885 | (1.802–1.973) | 1.322 | (1.226–1.426) |
Other Health Care Provider | 1.536 | (1.451–1.626) | 1.024 | (0.933–1.124) |
Educational Institution | 1.848 | (1.060–3.221) | 0.909 | (0.317–2.609) |
Employer | 1.823 | (1.332–2.495) | 1.414 | (0.904–2.210) |
Other Community Referral | 1.316 | (1.260–1.374) | 1.789 | (1.668–1.918) |
Court/Criminal Justice Referral/DUI | 2.270 | (2.204–2.338) | 1.805 | (1.716–1.899) |
Alcohol or Benzodiazepines Reported at Admission | 1.646 | (1.599–1.695) | 1.226 | (1.171–1.283) |
*Adjusted for year, state, age, sex, ethnicity, marital status, living arrangement, veteran status, years of education, employment status, primary source of income, health insurer, census division, service setting at time of admission, primary source of referral, and alcohol/benzodiazepine report at admission.
Only those aged 21–24 showed higher odds of waiting over a week to enter treatment compared to the reference group of those aged 18–20. No statistically significant difference in the odds of waiting over a week were found between men and women. Black or African Americans showed lower odds of waiting over a week to enter treatment compared to White Americans. Compared to those who were never married, those who were separated, divorced, or widowed showed higher odds of waiting over a week to enter treatment. Those in a dependent living situation or homeless showed lower odds of waiting over a week to enter treatment compared to those who reported living independently. No statistically significant difference was observed in the odds of waiting over a week to enter treatment between veterans and non-veterans. Those working part-time showed higher odds of waiting over a week to enter treatment vis-à-vis those working in full-time employment. Moreover, those reporting no primary source of income showed lower odds of waiting over a week to enter treatment than those reporting a primary income from wages/salary. Those covered by Medicaid showed lower odds of waiting over a week to enter treatment compared to those who were insured privately.
Admissions to all examined non-hospital settings were associated with lower odds of waiting over a week to enter treatment. Compared those who were individually referred for treatment (including self-referrals), those who were referred by an alcohol/drug abuse care provider, other community referrer, or the criminal justice system showed higher odds of waiting over a week to enter treatment. In addition, those reporting alcohol or benzodiazepines at admission also showed higher odds of waiting over a week to enter treatment.
Our findings highlight several differences in the receipt of OAT and waiting time to enter treatment on patient sociodemographic, institutional and behavioural characteristics. Firstly, we note that only a minority of patients admitted for OUD receive OAT with some subpopulations exhibiting much lower receipt of OAT than others. For instance, only 18% of those aged 18–20 received OAT compared to almost 60% of patients aged 55 and over who received OAT. Similarly, while approximately three-quarters of admitted patients were treated with no reported wait time, some subpopulations reported differentially higher rates of those waiting for over a week to enter treatment, such as those aged 18–20, those who were privately insured and those admitted to the hospital setting. Some subpopulations showed higher odds of receipt of OAT, including all age groups older than the reference group of patients aged 18–20, Native Americans, patients whose primary source of income was public assistance or retirement/pension or disability funds, those insured on Medicaid or Medicare, and those admitted to non-hospital care settings. By contrast, some groups showed lower odds of receipt of OAT, including those with a marital status other than the reference group who were never married, those in a dependent living situation or homeless, and those patients for whom the primary source of referral was anything other than an individual referral. With respect to covariates associated with increased odds of waiting over a week to enter treatment, our analysis highlighted several groups, including those who were separated, divorced, or widowed, those working part-time, and those who were referred by alcohol/drug abuse care providers, community referrers, or the criminal justice system.
Our analysis is necessarily limited by use of the TEDS-A dataset. Firstly, given the relative complexity of reporting from the facility to the state to the Federal level, variations on reporting mechanisms by state may have downstream effects on the quality of data at the national level [
Addressing differences in treating individuals affected by OUD is a chief concern for policymakers and care providers. One systematic review of determinants of opioid-related mortality in the United States and Canada has found opioid-related mortality trends tend to vary considerably by sociodemographic differences, including ethnicity, gender, age, and socioeconomic status, as we have highlighted here [
Our analysis highlights a number of areas for further scrutiny. Firstly, although OAT is widely considered the standard of care for OUD, only a minority of admitted patients receive it. Moreover, variations in who receives OAT and time to enter treatment based on sociodemographic and institutional characteristics highlight further areas for further study and potential intervention. In addition, further research is needed regarding personalised approaches to characterising the inheritable factors which contribute towards heightened risk of OUD as well as potential avenues for more effective treatment [