INTRODUCTION

Drug use disorders (DUDs) and associated overdose deaths are a growing public health concern in the USA, contributing to the first decrease in American life expectancy in over 100 years.1 Treatment for drug addiction remains uncommon despite the availability of evidence-based behavioral and pharmacologic treatments for many substances. We previously described the need for and barriers to alcohol use disorder care at federally funded US health centers,2 which provided safety-net care to more than 27 million Americans in 2017, but access to DUD care in this population remains underexplored. The objective of the current study was to examine the continuum of DUD care, location of treatment delivery, and barriers to receiving drug use treatment among health center attendees with symptoms of DUD.

METHODS

We analyzed data from adult (≥ 18 years old) respondents to the 2014 Health Center Patient Survey. This was a nationally representative, cross-sectional, in-person survey of Health Resources and Services Administration (HRSA) health center attendees conducted between September 2014 and April 2015 using a three-stage sampling design.3 We defined current DUD based on responses to the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test questionnaire,4 which includes items that assess past 3-month symptoms corresponding to 5 of 11 Diagnostic and Statistical Manual of Mental Disorders criteria for cannabis, cocaine, amphetamine-type stimulants, sedatives, inhalants, hallucinogens, and opioid use disorders. Individuals who endorsed ≥ 2 current symptoms for any substance were defined as having a diagnosis of DUD. We examined responses to a series of questions regarding receipt of DUD-related counseling and care, the location of this care, and the primary reason individuals were unable to access treatment. We examined whether these measures differed between health center subtypes where DUD was most common, Community Health Centers (CHC) and Health Care for the Homeless (HCH) programs. We conducted analyses in SAS (SAS Institute) v9.4, using strata, cluster, and weight variables to account for the complex sampling design and produce estimates representative of US health center attendees. Rao-Scott χ2 tests were used to compare proportions, with a two-sided p value < 0.05 for significance. The Partners Human Research Committee exempted this study.

RESULTS

Among 5547 adult patients, 374 (4.5%) had current evidence of DUD. The most common DUDs were cannabis (63.0%), sedative (16.8%), stimulant (14.1%), cocaine (13.7%), and opioid use disorder (7.7%). Two hundred ninety-three individuals (85.3%) had a single DUD, while 81 (14.7%) had DUDs involving two or more substances, most often cannabis (N = 49). Table 1 summarizes drug use disorders, demographic characteristics including clinic type, and health status differences between those with and without DUD.

Table 1 Characteristics of Patients With and Without Current Evidence of Drug Use Disorder at US Community Health Centers
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Half (49.7%) of those with a DUD reported discussing drug use with a health professional, 35.7% reported wanting or needing treatment, and 28.3% reported receiving treatment for DUD in the past year (Fig. 1). There were no significant differences between CHC and HCH attendees in reporting past-year discussion of drug use with a health care provider (49% vs. 55%, p = 0.54), wanting or needing DUD treatment (33% vs. 53%, p = 0.15), or receiving DUD treatment (26% vs. 45%, p = 0.16).

Figure 1
figure 1

Continuum of DUD care among health center attendees. Differences between Community Health Center and Health Care for the Homeless respondents are not statistically significant for any of the measures presented.

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Of 102 individuals who reported receiving past-year DUD treatment, 63% did so outside of a HRSA health center. Among 41 respondents who wanted but did not receive DUD treatment, the most commonly reported reasons for not obtaining treatment were stigma (69%), skepticism about treatment (14%), and logistical (12%) and financial barriers (5%).

DISCUSSION

DUDs were common in this representative study of health center attendees, providing estimates in line with other national samples.5 Cannabis use disorder was the most frequent DUD and often co-occurred with other substance use disorders. Only half of those with DUD discussed their drug use with a health professional, and fewer still reported wanting or receiving treatment for their drug use. Nearly two-thirds of individuals who received addiction treatment obtained it outside of their health center.

Limitations of this study include self-reported data about stigmatized conditions, an incomplete measure of DUD prevalence, and small sample sizes for some aspects of the analysis, limiting generalizability. While rising synthetic opioid and polysubstance drug use have contributed to drug overdose deaths nationally,6 drop-offs in engagement across the continuum of DUD care in this study highlight multiple addressable barriers to identifying individuals with substance use disorders and consistently linking them to effective addiction treatment from safety-net health centers.