This exploratory study used a survey with closed- and open-ended responses to describe barriers to addiction treatment in a small sample of recently-incarcerated adults with a SUD, a population among whom addiction treatment may be of paramount importance, is underutilized, and rarely tailored to their needs. Barriers to addiction treatment were frequently endorsed, but there were no barriers universally endorsed by this sample. Findings can be considered hypothesis-generating regarding barriers to treatment that might be specific to this population. These findings may be useful in informing future research and clinical efforts for individuals with a SUD with recent or current justice involvement.
Previous studies among justice-involved populations have identified lack of healthcare and related costs, limited availability of qualified healthcare providers, long wait times, stigma, and criminal justice agencies’ procedures and preferences (e.g., exclusion of medication-assisted treatments due to preference to be “drug-free”) as barriers to treatment [4, 5, 7, 18, 19, 29]. There were similarities in findings between studies on barriers to treatment with other justice-involved samples and the current study. Among justice-involved individuals choosing to attend treatment in lieu of incarceration,  23.9% expressed no desire for treatment, which is similar to 25.0% of the current sample reporting “I do not think I need treatment”. Rose et al. (2014) found that women incarcerated in jail also reported long wait lists as a barrier to treatment, although this was more common among this sample of women than the current sample (58.9% vs. 28.6%) . Unfortunately, it often is difficult to make comparisons across studies due to variability in assessing barriers and differing samples. The present study is small, but potentially broader in inclusion criteria than previous studies, and adds to these previous studies by expanding the assessment of barriers. Indeed, we found that barriers not previously identified may be important to consider for this population, including perceiving Absence of Problem and Privacy Concerns. Knowledge of these potential barriers in combination with those previously identified in justice-involved individuals, such as Ambivalence, may provide counselors and criminal justice staff with more nuanced information to assist their clients in overcoming obstacles to seeking or staying in treatment.
A previous study also used the BTI, but with a sample of general treatment-seeking individuals with a SUD,  which presented the opportunity to compare rates of barriers to the current sample of justice-involved individuals with a SUD. Among this sample of treatment-seeking individuals, barriers to treatment included the Fear of Treatment, Time Conflict, and Poor Treatment Availability, which also were endorsed by similar proportions of the current study sample. It is noteworthy, however, that participants in the present study sample endorsed Absence of Problem at a markedly higher rate than what was reported by Rapp et al., such as, “I do not think I have a problem with drugs” (42.8% vs. 12.5%) and “My drug use is not causing any problems” (32.2% vs. 8.0%). These discrepancies may be because the sample from Rapp et al. already had initiated the process of seeking addiction treatment, which often includes an acknowledgement of engaging in problematic substance use, compared to the current sample, who were not necessarily treatment-seeking. Alternatively, the present study selected for people reporting moderate to high alcohol use who may not have had much drug involvement. Because we did not alter the original scale to include both drugs and alcohol in these items, we may have inadvertently overestimated the degree to which our participants felt they had an “Absence of Problem.” However, half of the sample met criteria for a current drug use disorder, suggesting that many individuals in this sample still were experiencing problems related to their drug use.
Though our sample was small, an interesting finding was the relatively few endorsements of barriers in the Negative Social Support domain. Specifically, participants in the present study did not endorse four of the five items, and only a small number endorsed “Friends tell me not to go to treatment” (n = 3, 10.7%). In contrast, these barriers were more frequently endorsed by the treatment-seeking sample of individuals with a SUD reported by Rapp et al., although still in low proportions (proportions of agreement ranged from 7.4 to 16.0%) . This finding suggests the possibility that justice-involved individuals with a SUD experience barriers related to Negative Social Support less frequently. While future research is needed to further explore this finding, these results suggest a possible intervention pathway—via the involvement of friends and family to encourage treatment engagement. Additionally, these findings may indicate that resources should be diverted to addressing other barriers, where they may have more impact.
In exploratory, post hoc analyses comparing barriers between participants randomly assigned to treatment conditions, barriers generally were endorsed by similar proportions. Groups did, however, differ on two items from the Absence of Problem domain (“I do not have a problem with drugs”, “I can handle my drug use on my own”), with participants assigned to the motivational intervention reporting these barriers more frequently than those assigned to the education intervention. These findings are hypothesis-generating in suggesting that motivational interventions may not be helpful for increasing problem recognition among justice-involved individuals with a SUD, as they are designed to do, or may be unhelpful in this domain. Other studies with jail populations found null results of motivational interventions on other outcomes such as treatment engagement . Of note, our results should be interpreted with caution, given the small sample, post hoc nature of these analyses, multiple comparisons, and that the parent study did not include a no-treatment control condition.
Similarly, in post hoc analyses comparing barriers reported between groups based on post-release treatment seeking, groups largely were similar. However, those who reported seeking treatment reported less apprehension about talking in groups or being asked personal or intrusive questions as a barrier. These findings highlight privacy as a potential concern among those who did not seek treatment, which may have clinical implications. This non-treatment-seeking group may prefer individual treatment or find pharmacotherapy less invasive and more beneficial than psychotherapy. However, research is needed in larger samples of justice-involved adults with a SUD who have and have not sought treatment to further explore this issue, and examine if pharmacotherapy could be a viable option for those with Privacy Concerns.
Findings from the present study suggest the possibility that barriers beyond those commonly identified may exist in this population. Two participants specifically referenced issues related to their justice involvement in the reporting of additional barriers that were coded under a priori domains (“Just pending court dates” coded as Time Conflict; and “Just my misdemeanor situation prevents inpatients treatments to accept me” coded as Admission Difficulty). Though justice-involvement was not, on its own, coded as an emergent barrier domain, it is possible that this population experiences specific enhanced barriers to treatment that were not cued by the generally phrased open-ended question we used regarding potential additional barriers to treatment. Additionally, it would be useful to better understand potential barriers identified with more in-depth qualitative work. For example, it would be informative to know if “pending court dates” refer to multiple demands on time or waiting to start treatment to know exact sentencing requirements, as well as to know how a “misdemeanor situation” may prevent someone from entering inpatient treatment (e.g., if someone is precluded from treatment while they wait for court dates). We had limited ability to assess these issues due to both small sample size and administration of one open-ended question without the opportunity to probe. Nonetheless, our study is hypothesis-generating regarding the need for broadening measures of barriers to treatment for persons involved with the criminal justice system, which can then inform future interventions for this population.
The present study is limited in several additional ways. First, this study had a small sample and thus the results presented here should be considered descriptive and hypothesis-generating. Given the small sample, we likely were underpowered to detect between-group differences across treatment condition assignment and report of post-release treatment receipt. The multiple exploratory comparisons we conducted between groups increase the risk of making a Type II error. Moreover, findings may not be representative of justice-involved individuals with a SUD more generally (e.g., those who are arrested without ever being incarcerated) because the sample only included individuals who were sentenced, had a substance use-related charge, were being released from a large Southwest detention center, and agreed to participate in a clinical trial, and recruitment targeted those with an alcohol use disorder (e.g., some may not have identified with needing “drug treatment”); this study also excluded those in the methadone maintenance program. The study recruited for individuals with an alcohol use disorder, but many questions of the BTI use language referring to drug use specifically (e.g., “I do not think I have a problem with drugs”), which may have influenced responses to these BTI items and resulted in overestimates of these barriers. Findings also may not be generalizable to women, and there may be additional barriers experienced by women not reflected in these results (e.g., competing basic needs related to childcare, added stigma ). Findings also may be biased by loss to follow-up. Though we compared participants across follow-up status and identified no differences, participants who did not complete either follow-up interview may experience more or different barriers to treatment (e.g., lacking reliable access to a phone, which may make it difficult to seek out treatment services). Further, many participants already had made changes to their alcohol and/or drug use by the time they completed the follow-up interview, which may have influenced their perceived need for treatment. Because this study was a secondary analysis of a pilot parent study that was not designed to investigate issues related to barriers to treatment, we may have missed some barriers to treatment (e.g., barriers to addiction treatment related to cost and lack of healthcare coverage did not emerge), which are commonly reported in the literature [5, 16]. We also did not assess some key issues that may influence barriers to treatment, such as conditions of release or probation or parole requirements (e.g., having more probation appointments interfering with ability to attend treatment) or provide external incentives to engage in treatment (e.g., SUD treatment is a condition of probation and compliance is associated with remaining out of jail or prison). Finally, participants were not given prompts or further opportunity to expand on potential barriers to treatment, as the BTI is a self-report measure rather than an interview.