Disparities in the Treatment of Substance Use Disorders: Does Where You Live Matter?

A Correction to this article was published on 08 October 2018

This article has been updated


This study focused on (1) whether disparities in timely receipt of substance use services can be explained in part by the characteristics of the community in which the clients reside and (2) whether the effect of community characteristics on timely receipt of services was similar across racial/ethnic groups. The sample was composed of adults receiving publicly funded outpatient treatment in Washington State. Treatment data were linked to data from the US census. The outcome studied was “Initiation and Engagement” in treatment (IET), a measure noting timely receipt of services at the beginning of treatment. Community characteristics studied included community level economic disadvantage and concentration of American Indian, Latino, and Black residents in the community. Black and American Indian clients were less likely to initiate or engage in treatment compared to non-Latino white clients, and American Indian clients living in economically disadvantaged communities were at even greater risk of not initiating treatment. Community economic disadvantage and racial/ethnic makeup of the community were associated with treatment initiation, but not engagement, although they did not entirely explain the disparities found in IET.

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Figure 1

Change history

  • 08 October 2018

    The professional degree of co-author Kevin Campbell is incorrect. It should be “DrPH” and not “PhD”.

  • 08 October 2018

    The professional degree of co-author Kevin Campbell is incorrect. It should be ?DrPH? and not ?PhD?.


  1. 1.

    SAMHSA. 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration;2016.

  2. 2.

    Schmidt LA, Ye Y, Greenfield TK, et al. Ethnic disparities in clinical severity and services for alcohol problems: results from the National Alcohol Survey. Alcoholism, clinical and experimental research. 2007;31(1):48–56.

    Article  Google Scholar 

  3. 3.

    Keyes KM, Liu XC, Cerda M. The role of race/ethnicity in alcohol-attributable injury in the United States. Epidemiologic Reviews. 2012;34:89–102.

    Article  Google Scholar 

  4. 4.

    Snyder HN, Mulako-Wangota J, Bureau of Justice Statistics. Arrests by Race and Age in the U.S., 2012. In. Generated using the Arrest Data Analysis Tool at www.bjs.gov . (December 30, 2015).2015.

  5. 5.

    Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug and alcohol dependence. 2013;131(3):263–270.

    Article  Google Scholar 

  6. 6.

    Mack K. Drug-induced deaths - United States, 1999-2010 Morbidity and Mortality Weekly Report. 2013;62 Suppl 3:161–163.

    Google Scholar 

  7. 7.

    Cook BL, Alegría M. Racial-ethnic disparities in substance abuse treatment: The role of criminal history and socioeconomic status. Psychiatric Services. 2011;62(11):1273–1281.

    Article  Google Scholar 

  8. 8.

    Acevedo A, Garnick DW, Lee MT, et al. Racial and ethnic differences in substance abuse treatment initiation and engagement. Journal of ethnicity in substance abuse. 2012;11(1):1–21.

    Article  Google Scholar 

  9. 9.

    Acevedo A, Garnick DW, Dunigan R, et al. Performance measures and racial/ethnic disparities in the treatment of substance use disorders. Journal on the Studies of Alcohol & Drugs. 2015;76(1):57–67.

    Article  Google Scholar 

  10. 10.

    Saloner B, Cook BL. Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Affairs. 2013;32(1):135–145.

    Article  Google Scholar 

  11. 11.

    Guerrero EG, Marsh JC, Duan L, et al. Disparities in completion of substance abuse treatment between and within racial and ethnic groups. Health services research. 2013;48(4):1450–1467.

    Article  Google Scholar 

  12. 12.

    Mennis J, Stahler GJ. Racial and Ethnic Disparities in Outpatient Substance Use Disorder Treatment Episode Completion for Different Substances. Journal of substance abuse treatment. 2016;63:25–33.

    Article  Google Scholar 

  13. 13.

    Lundgren LM, Amaro H, Ben-Ami L. Factors Associated with Drug Treatment Entry Patterns Among Hispanic Women Injection Drug Users Seeking Treatment. Journal of Social Work Practice in the Addictions. 2005;5(1–2):157–174.

    Article  Google Scholar 

  14. 14.

    Cummings JR, Wen H, Ko M, et al. Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States. JAMA Psychiatry. 2014;71(2):190–196.

    Article  Google Scholar 

  15. 15.

    Jacobson JO, Robinson P, Bluthenthal RN. A multilevel decomposition approach to estimate the role of program location and neighborhood disadvantage in racial disparities in alcohol treatment completion. Social Science & Medicine. 2007;64(2):462–476.

    Article  Google Scholar 

  16. 16.

    Karriker-Jaffe KJ, Zemore SE, Mulia N, et al. Neighborhood disadvantage and adult alcohol outcomes: differential risk by race and gender. Journal on the Studies of Alcohol and Drugs. 2012;73(6):865–873.

    Article  Google Scholar 

  17. 17.

    Jones-Webb R, Snowden L, Herd D, et al. Alcohol-related problems among black, Hispanic and white men: the contribution of neighborhood poverty. Journal of studies on alcohol. 1997;58(5):539–545.

    CAS  Article  Google Scholar 

  18. 18.

    Saloner B, Carson N, Le Cook B. Explaining racial/ethnic differences in adolescent substance abuse treatment completion in the United States: a decomposition analysis. Journal of Adolescent Health. 2014;54(6):646–653.

    Article  Google Scholar 

  19. 19.

    Andersen RM, Davidson PL, Kominski GF. Improving Access to Care in America: Individual and Contextual Indicators. In: Andersen RM, Rice TH, Kominski GF, eds. Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management. San Francisco: Jossey-Bass Inc.; 2007:3–32.

    Google Scholar 

  20. 20.

    National Quality Forum. NQF Endorsed Standards. 2017; http://www.qualityforum.org/MeasureDetails.aspx?SubmissionID=1245. Accessed 05/01/17.

  21. 21.

    National Committee for Quality Assurance. NCQA HEDIS 2016. 2016; http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2016.aspx. Accessed 05/06/17.

  22. 22.

    Harris AH, Humphreys K, Bowe T, et al. Does meeting the HEDIS substance abuse treatment engagement criterion predict patient outcomes? Journal of Behavioral Health Services Research. 2010;37(1):25–39.

    Article  Google Scholar 

  23. 23.

    Garnick DW, Lee MT, Horgan C, et al. Lessons from five states: public sector use of the Washington Circle performance measures. Journal of substance abuse treatment. 2011;40(3):241–254.

    Article  Google Scholar 

  24. 24.

    Garnick DW, Lee MT, Horgan CM, et al. Adapting Washington Circle performance measures for public sector substance abuse treatment systems. Journal of substance abuse treatment. 2009;36(3):265–277.

    Article  Google Scholar 

  25. 25.

    Dunigan R, Acevedo A, Campbell K, et al. Engagement in outpatient substance abuse treatment and employment outcomes. Journal of Behavioral Health Services Research. 2014;41(1):20–36.

    Article  Google Scholar 

  26. 26.

    Garnick DW, Horgan CM, Acevedo A, et al. Criminal justice outcomes after engagement in outpatient substance abuse treatment. Journal of substance abuse treatment. 2014;46(3):295–305.

    Article  Google Scholar 

  27. 27.

    Acevedo A, Garnick D, Ritter G, et al. Admissions to detoxification after treatment: Does engagement make a difference? Substance Abuse. 2016;37(2):364–371.

    Article  Google Scholar 

  28. 28.

    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002.

    Google Scholar 

  29. 29.

    Cook BL, McGuire TG, Zuvekas SH. Measuring trends in racial/ ethnic health care disparities. Medical Care Research and Review. 2009;66(1):23–48.

    Article  Google Scholar 

  30. 30.

    Norris T, Vines P, Hoeffel E. Census Briefs: The American Indian and Alaska Native Population: 2010. 2012; https://www.census.gov/content/dam/Census/library/publications/2012/dec/c2010br-10.pdf. Accessed May 5, 2017.

  31. 31.

    Cohn D. American Indian and white, but not ‘multiracial’. 2015; http://www.pewresearch.org/fact-tank/2015/06/11/american-indian-and-white-but-not-multiracial/. Accessed May 5, 2017.

  32. 32.

    Krieger N, Chen JT, Waterman PD, et al. Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures--the public health disparities geocoding project. American Journal of Public Health. 2003;93(10):1655–1671.

    Article  Google Scholar 

  33. 33.

    U.S. Census Bureau. Geographic Terms and Concepts - Census Tract. 2012; https://www.census.gov/geo/reference/gtc/gtc_ct.html. Accessed March 3, 2017.

  34. 34.

    Mennis J, Stahler GJ, Baron DA. Geographic Barriers to Community-Based Psychiatric Treatment for Drug-Dependent Patients. Annals of the Association of American Geographers. 2012;102(5):1093–1103.

    Article  Google Scholar 

  35. 35.

    Molina KM, Alegria M, Chen CN. Neighborhood context and substance use disorders: a comparative analysis of racial and ethnic groups in the United States. Drug and alcohol dependence. 2012;125 Suppl 1:S35–43.

    Article  Google Scholar 

  36. 36.

    Karriker-Jaffe KJ. Neighborhood socioeconomic status and substance use by U.S. adults. Drug and alcohol dependence. 2013;133(1):212–221.

    Article  Google Scholar 

  37. 37.

    Lee MT, Garnick DW, O'Brien PL, et al. Adolescent treatment initiation and engagement in an evidence-based practice initiative. Journal of substance abuse treatment. 2012;42(4):346–355.

    Article  Google Scholar 

  38. 38.

    StataCorp. Heckman two-stage procedure. Stata Statistical Software: Release 11. College Station, TX: StataCorp LP; 2009.

  39. 39.

    Hosmer D, Lemeshow S, Sturdivant R. Applied Logistic Regression. 3rd ed. Hoboken, New Jersey: Wiley & Sons; 2013.

    Google Scholar 

  40. 40.

    Cook BL, McGuire TG, Zaslavsky AM. Measuring racial/ethnic disparities in health care: methods and practical issues. Health services research. 2012;47(3 Pt 2):1232–1254.

    Article  Google Scholar 

  41. 41.

    Legha R, Raleigh-Cohn A, Fickenscher A, et al. Challenges to providing quality substance abuse treatment services for American Indian and Alaska native communities: perspectives of staff from 18 treatment centers. BMC psychiatry. 2014;14(1):181.

    Article  Google Scholar 

  42. 42.

    Novins DK, Croy CD, Moore LA, et al. Use of evidence-based treatments in substance abuse treatment programs serving American Indian and Alaska Native communities. Drug and alcohol dependence. 2016;161:214–221.

    Article  Google Scholar 

  43. 43.

    Rieckmann T, Moore LA, Croy CD, et al. A National Study of American Indian and Alaska Native Substance Abuse Treatment: Provider and Program Characteristics. Journal of substance abuse treatment. 2016;68:46–56.

    Article  Google Scholar 

  44. 44.

    McFarland BH, Gabriel RM, Bigelow DA, et al. Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives. American Journal of Public Health. 2006;96(8):1469–1477.

    Article  Google Scholar 

  45. 45.

    Kropp F, Lilleskov M, Richards J, et al. Client and provider views on access to care for substance-using American Indians: perspectives from a Northern Plains urban clinic. American Indian and Alaska native mental health research (Online). 2014;21(2):43.

    Article  Google Scholar 

  46. 46.

    Kramer MR, Hogue CR. Is segregation bad for your health? Epidemiologic Reviews. 2009;31:178–194.

    Article  Google Scholar 

  47. 47.

    White K, Haas JS, Williams DR. Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation. Health services research. 2012;47(3 Pt 2):1278–1299.

    Article  Google Scholar 

  48. 48.

    Romley JA, Cohen D, Ringel J, et al. Alcohol and Environmental Justice: The Density of Liquor Stores and Bars in Urban Neighborhoods in the United States. Journal of studies on alcohol and drugs. 2007;68(1):48–55.

    Article  Google Scholar 

  49. 49.

    Berke EM, Tanski SE, Demidenko E, et al. Alcohol retail density and demographic predictors of health disparities: a geographic analysis. American Journal of Public Health. 2010;100(10):1967.

    Article  Google Scholar 

  50. 50.

    Stahler GJ, Mazzella S, Mennis J, Chakravorty S, Rengert G, Spiga R. The effect of individual, program, and neighborhood variables on continuity of treatment among dually diagnosed individuals. Drug and Alcohol Dependence. 2007;87(1):54–62.

    Article  Google Scholar 

  51. 51.

    Dimick J, Ruhter J, Sarrazin MV, et al. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions. Health Affairs. 2013;32(6):1046–1053.

    Article  Google Scholar 

  52. 52.

    Guerrero EG, Kao D, Perron BE. Travel distance to outpatient substance use disorder treatment facilities for Spanish-speaking clients. International Journal of Drug Policy. 2013;24(1):38–45.

    Article  Google Scholar 

  53. 53.

    Rosenblum A, Cleland CM, Fong C, Kayman DJ, Tempalski B, Parrino M. Distance traveled and cross-state commuting to opioid treatment programs in the United States. Journal of Environmental and Public Health. 2011;2011:1–10.

    Article  Google Scholar 

  54. 54.

    Gaskin DJ, Dinwiddie GY, Chan KS, McCleary R. Residential segregation and disparities in health care services utilization. Medical Care Research Review. 2012;69(2):158–175.

    Article  Google Scholar 

  55. 55.

    Dinwiddie GY, Gaskin DJ, Chan KS, Norrington J, McCleary R. Residential segregation, geographic proximity and type of services used: evidence for racial/ethnic disparities in mental health. Social science & medicine. 2013;80:67–75.

    Article  Google Scholar 

  56. 56.

    Mark TL, Levit KR, Vandivort-Warren R, Buck JA, Coffey RM. Changes In US spending on Mental Health And Substance Abuse Treatment, 1986-2005, and implications for policy. Health affairs. 2011;30(2):284–292.

    Article  Google Scholar 

  57. 57.

    Mark TL, Levit KR, Yee T, Chow CM. Spending on mental and substance use disorders projected to grow more slowly than all health spending through 2020. Health affairs. 2014;33(8):1407–1415.

    Article  Google Scholar 

  58. 58.

    Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: NSDUH Series H-44, HHS Publication No. (SMA) 2013;13–4795.

  59. 59.

    Substance Abuse and Mental Health Services Administration. Racial and Ethnic Minority Populations. Specific Populations 2016; https://www.samhsa.gov/specific-populations/racial-ethnic-minority. Accessed 9/14/17.

  60. 60.

    Archibald ME, Putnam Rankin C. A spatial analysis of community disadvantage and access to healthcare services in the U.S. Social science & medicine. 2013;90:11–23.

    Article  Google Scholar 

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The authors would like to thank Can Du from the Behavioral Health Administration in the Washington State Department of Social and Health Services for her comments on an earlier version of the manuscript.


This research was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under award number R03AA023390. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or of the participating state.

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Correspondence to Andrea Acevedo PhD.

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Acevedo, A., Panas, L., Garnick, D. et al. Disparities in the Treatment of Substance Use Disorders: Does Where You Live Matter?. J Behav Health Serv Res 45, 533–549 (2018). https://doi.org/10.1007/s11414-018-9586-y

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  • Treatment
  • Disparities
  • Community
  • Quality