Sociodemographic Factors in Drug Abuse Treatment

49 Presentation SOCIODEMOGRAPHIC FACTORS IN DRUG ABUSE TREATMENT DAVID A. GORELICK, M.D., Ph.D. Clinical Professor of Psychiatry University of Maryland School of Medicine; Chief, Treatment Branch Addiction Research Center National Institute on Drug Abuse Post Office Box 5180 Baltimore, MD 21224 Illicit drug abuse is A major public health problem in the United States, one that affects all segments of the population. The problem is exacerbated when it occurs among sociodemographic groups—racial /ethnic minorities, the poor, the homeless, and those living in rural areas—that tend to be underserved by the health care and drug abuse treatment systems in this country. The existing clinical and scientific literature on drug abuse treatment often ignores the role of racial/ethnic, cultural, and other sociodemographic factors. For example, a recent survey of 26 comprehensive books on alcoholism or substance abuse published between 1975 and 1989 found that 10 (38 percent) made no mention of racial factors.1 A recent exhaustive review of success rates in detoxification from methadone maintenance treatment for opiate dependence included no discussion of sociodemographic factors.2 This neglect gives the implicit impression that drug abusers are a homogeneous population, and that sociodemographic factors are irrelevant to drug abuse treatment. Even studies that consider sociodemographic factors tend to oversimplify. Nonwhites are often treated as homogeneous3, ignoring, for example, the ethnic and cultural differences among blacks, Hispanics, Asians, and Native Americans or among the various Hispanic groups in the United States.4 Studies using race as a factor often ignore socioeconomic status, giving the implication that in drug abuse treatment, the former is more important than the latter.5 Journal of Health Care for the Poor and Underserved, Vol. 3, No. 1, Summer 1992 50 Sociodemographic Factors in Drug Abuse Treatment The neglect of sociodemographic factors in the published literature on drug abuse treatment is even more noteworthy considering that most published data are drawn from government-run or publicly funded (rather than private) treatment programs. Racial/ethnic minorities and the poor are well represented , if not overrepresented, among patients in such programs. However, without more systematic data across a range of sociodemographic groups and types of treatment programs, it is impossible to draw valid conclusions about the relative access to treatment or about treatment outcomes of different sociodemographic groups. This paper provides a brief, selective overview of recently published studies of the sociodemographic characteristics of patients in drug abuse treatment; the influence of these sociodemographic characteristics on diagnosis, referral, treatment compliance and retention, and treatment outcome; and the gaps in our knowledge that deserve further study. It does not cover two other important related topics: the role of gender in drug abuse treatment, and the role of sociodemographic factors in licit (i.e., alcohol, tobacco, prescription medication ) drug abuse. For the sake of brevity, the term "drug abuse" includes drug dependence as defined by psychiatric diagnosis6, and "substance abuse" includes both alcoholism and illicit drug abuse. Epidemiology Epidemiologic studies over the past decade indicate the prevalence of illicit drug use and abuse in all segments of the United States population, including those likely to be underserved by the drug abuse treatment system. While most of these studies characterize the racial make-up of the studied population, many do not provide information on specific ethnic background or other sociodemographic factors such as income, employment, or occupational status. For example, during the early 1980s, the National Institute of Mental Health-sponsored Epidemiologic Catchment Area (ECA) study assessed the prevalence of drug use and abuse (and other psychiatric disorders) among a representative random sample of 19,182 adult Americans living in and around five different U.S. cities: New Haven; Baltimore; Durham, North Carolina; St. Louis; and Los Angeles.7 The overall lifetime prevalence of drug use (excluding alcohol and tobacco) was 30.5 percent, and of drug abuse, 6.2 percent. The current prevalences were 2.7 percent (one-year) and 1.3 percent (one-month). The ECA study found some significant correlations between sociodemographic factors and differences in the prevalence of drug abuse, although the epidemiologic data do not allow one to distinguish between risk factors for abuse and the consequences of abuse. For example, whites (30.7...