• Previous research has shown treatment for alcohol use disorders (AUD) differs by race/ethnicity. However, no research has examined how many veterans with a diagnosis of AUD initiate and engage with treatment from an addictions specialist. This study analyzes data from 302,406 veterans diagnosed with AUD who received care from the US Veterans Health Administration (VHA) in 2012.
• There is a significant difference in the percent of black, Hispanic and white veterans who began treatment within 180 days of an AUD diagnosis. Thirty-eight percent of black veterans reported receiving some type of addictions treatment following their diagnosis, compared with 32 percent of Hispanic veterans and 27percent of white veterans. Black veterans were also 1.36 times more likely to engage (defined as more than 3 visits in the first month or at least 2 visits for three months) in treatment than white Veterans.
• The findings suggest that black and Hispanic veterans are more likely to receive treatment for alcohol related disorders than white veterans. More research is needed to determine the long-term health impact of treatment on these groups.
Objective: Specialty addictions treatment can improve outcomes for patients with alcohol use disorders (AUD). Thus, initiation of and engagement with specialty addictions treatment are considered quality care for patients with AUD. Previous studies have demonstrated racial/ethnic differences in alcohol-related care but whether differences exist in initiation of and engagement with specialty addictions treatment among patients with clinically recognized alcohol use disorders is unknown. We investigated racial/ethnic variation in initiation of and engagement with specialty addictions treatment in a national sample of Black, Hispanic, and White patients with clinically recognized alcohol use disorders (AUD) from the US Veterans Health Administration (VA).
Methods: National VA data were extracted for all Black, Hispanic, and White patients with a diagnosed AUD during fiscal year 2012. Mixed effects regression models estimated the odds of two measures of initiation (an initial visit within 180 days of diagnosis; and initiation defined consistent with Healthcare Effectiveness Data and Information Set (HEDIS) as a documented visit ≤14 days after index visit or inpatient admission), and three established measures of treatment engagement (≥3 visits within first month after initiation; ≥2 visits in each of the first 3 months after initiation; and ≥2 visits within 30 days of HEDIS initiation) for Black and Hispanic relative to White patients after adjustment for facility- and patient-level characteristics.
Results: Among 302,406 patients with AUD, 30% (90,879) initiated treatment within 180 days of diagnosis (38% Black, 32% Hispanic, and 27% White). Black patients were more likely to initiate treatment than Whites for both measures of initiation [odds ratio (OR) for initiation: 1.4, 95% confidence interval (CI) 1.4–1.4; OR for HEDIS initiation: 1.1, 95% CI: 1.1–1.1]. Hispanic patients were more likely than White patients to initiate treatment within 180 days (OR: 1.2, 95% CI 1.2–1.3) but HEDIS initiation did not differ between Hispanic and White patients. Engagement results varied depending on the measure but was more likely for Black patients relative to White for all measures (OR for engagement in first month: 1.1, 95% CI: 1.0–1.1; OR for engagement in first three months: 1.2, 95% CI: 1.1–1.2; OR for HEDIS measure: 1.1, 95% CI: 1.0–1.1), and did not differ between Hispanic and White patients.
Conclusions: After accounting for facility- and patient-level characteristics, Black and Hispanic patients with AUD were more likely than Whites to initiate specialty addictions treatment, and Black patients were more likely than Whites to engage. Research is needed to understand underlying mechanisms and whether differences in initiation of and engagement with care influence health outcomes.
To decrease the long-term negative health effects of alcohol misuse, veterans should be open to engaging in treatment programs recommended by their health care providers. Families of veterans who are misusing alcohol should encourage their veteran to participate in a treatment program and seek other necessary medical care. Families should remain willing to engage in conversations with their veteran in an attempt to support their veteran during the recovery process. Primary care providers (PCPs) should provide veterans information about alcohol dependence and how to best prevent and treat it. PCPs should also discuss AUD with veterans they suspect are struggling with it and when applicable, provide referrals to the appropriate addiction specialists. Providers and treatment programs should be accessible and make contacting them easy, as it appears veterans are more likely to engage in treatment if they initiate the contact. Media should run public service announcements that provide truthful information on mental health and substance abuse.
The Department of Defense (DoD) might help engage transitioning service members in treatment by providing educational opportunities before they leave the service. During the transition period, the DoD might provide information about when veterans should receive screenings and also different strategies that may help them cope with stress that do not involve using alcohol or other substances. The Department of Veterans Affairs, (VA) might conduct research on barriers that prevent veterans from initiating treatment. The VA might also consider making changes to its treatment programs to reach a greater number of veterans. Changes the VA might consider are increased number of treatment programs and online programs for veterans in rural areas. The VA might also continue offering the programs at various times to accommodate the most veterans. The VA might evaluate if additional peer mentoring and support networks are needed to support veterans who are struggling with AUD. Policymakers might review how barriers can be reduced to help veterans and civilians engage in treatment programs. Barriers policymakers might review include costs for treatment programs and employment concerns. Policymakers could increase accessibility of treatment programs by allocating funds to groups which support substance use education and rehabilitation.
For Future Research
One limitation of the current study was that it only drew from a small sample of veterans engaging in care at the VA during one fiscal year. Additional research should be conducted to determine how these rates compare to the rates of veterans in substance abuse treatment at non-VA facilities. Future studies should report the rate of initiation and engagement in treatment separately for AUD alone and AUD combined with another substance use disorder. More research is needed on how treatment programs can best support black and Hispanic veterans with an AUD. Qualitative studies should explore veteran’s self-reported reasons for initiating treatment. Past research has consistently shown different mental health and treatment utilization rates between veterans who were officers and those who were enlisted service members. Future studies should collect and analyze data concerning the differences in the initiation and engagement of treatment by these two populations. Research should also expand the definition of initiation of treatment. Another limitation of the current study was that the acceptable window to initiate in treatment was rather small. Future researchers should examine the time frame in which most veterans initiate treatment. Longitudinal studies should be collected to determine the long-term health consequences of such decisions.