Summary
During the worsening overdose crisis in the United States, medications for opioid use disorder (MOUD) are our most effective treatment but remain critically underutilized. Among those with OUD, psychiatric comorbidity is common. Expanding availability of MOUD within psychiatric care has enormous potential impact in improving the care of people with co-morbid OUD and mental illness. To date, there is no data describing MOUD availability within psychiatric hospitals. Analyzing a cross-sectional analysis of facility-level responses to the 2022 National Substance Use and Mental Health Services Survey (N-SUMHSS), we found that less than half (48%) of psychiatric hospitals in the United States offer MOUD. There was no correlation between MOUD availability and 1) self-reported prevalence of co-morbid substance use disorders (SUD’s) and mental illness within a psychiatric hospital or 2) state overdose mortality.
This study identifies a treatment gap in the availability of evidence-based MOUD within psychiatric care. Closing this gap has the potential save lives and improve both OUD and psychiatric outcomes in those hospitalized. Further research should focus on how to improve MOUD provision within psychiatric hospitals through qualitative studies identifying barriers specific to psychiatric hospitals and implementation studies on MOUD expansions similar to those at other clinical sites such as the emergency department. Improving education on evidence-based treatment of OUD for psychiatric clinicians will be a key component to improving care. 

Background
In the midst of an unprecedented overdose crisis,1 medications for opioid use disorder (MOUD), namely methadone and buprenorphine, remain the most effective treatment for opioid use disorder (OUD) reducing mortality by 50% in some instances.2 Yet, MOUD remains underutilized with less than 1 in 5 people with OUD currently receiving this form of treatment (cite NSDUH).3-5 Expanding meaningful access to MOUD in all healthcare settings is a critical step in addressing the overdose crisis and saving lives.

Psychiatric comorbidity is common among patients with OUD. Recent national data demonstrate a 64% prevalence of any mental illness among those with OUD with 27% having severe mental illness (SMI). 6 Specifically, among those with OUD, the prevalence of depression and anxiety were 36%, and 29% respectively,7 with smaller studies showing markedly high rates of suicidal thoughts as well.8 Engagement in treatment among those with co-morbid SUD and mental illness is rare with only 13% of people currently engaged in care for both conditions.9 Access to treatment in this population is particularly critical given they are disproportionately disadvantaged,10 experience more severe physical and psychological impairment,11, 12 have high utilization of health services,13, 14 and have many barriers to healthcare access.15 Therefore, optimizing access to MOUD within psychiatric treatment settings has an outsized potential impact on treatment trajectories of those with OUD.16

Psychiatric hospitals provide specialized inpatient care for people with mental illness with severe manifestations requiring intensive supervised treatment including medication and psychotherapy. To date, no studies have assessed the availability of MOUD at psychiatric hospitals. We aimed to describe MOUD availability at psychiatric hospitals throughout the United States using national data. 

Methods
This is a cross-sectional analysis of facility-level responses to the 2022 National Substance Use and Mental Health Services Survey (N-SUMHSS).17 Study participants included all facilities in the United States (50 states and Washington D.C.) responding to the 2022 N-SUMHSS survey that self-report their facility type as a psychiatric hospital. Our primary outcome is a dichotomous variable indicating whether medications for opioid use disorder is a service that psychiatric hospitals report providing. We conducted two main analyses. In the first analyses, the predictor is the psychiatric hospitals’ reported percentage of patients with co-occurring mental health and SUDs. In the second analyses, we assessed the probability of MOUD provision with 2021 state overdose rates per 100,000 population.

Results
Of 1,107 psychiatric hospitals who responded, information on MOUD provision was available for 1,021 (92% response rate). Less than half of psychiatric hospitals (48%) report that they provide MOUD. Among facilities reporting MOUD provision, 853 psychiatric hospitals reported the percentage of patients with co-occurring SUDs (84% response rate), the mean was 30% (med=30%, IQR= 5%, 50%) including 22% reporting having no patients with a SUD. Psychiatric hospitals that had a higher percentage of patients with a co-occurring substance use disorder were not more likely to provide MOUD (β=.001, P=.073). MOUD availability at psychiatric hospitals by state was highly variable ranging from 0% to 100% (median=48%, IQR=33%, 65%). Facility-level probability of MOUD provision was not associated with 2021 state overdose mortality rates (β=.003, p=0.054). 

Conclusion
In a national survey of psychiatric hospitals, provision of MOUD was available in less than half of psychiatric hospitals. The lack of correlation between provision of MOUD and both prevalence of co-occurring SUDs and mental illness as well state overdose mortality rates illustrate that psychiatric hospital’s provision of MOUD appears to be unrelated to patient need. Future research should focus on improving MOUD provision within psychiatric hospitals through qualitative studies identifying barriers specific to psychiatric hospitals and psychiatric clinicians. Implementation studies on how to improve provision may be similar to the effort currently being made in expand buprenorphine access in emergency departments and HIV clinics.19 Improving education on evidence-based treatment of OUD for psychiatric clinicians will be a key component to improving care.  

Scientific Significance
This study identifies an overlooked gap in the availability of evidence-based medications for opioid use disorder within psychiatric care. The unavailability of MOUD within psychiatric hospitals likely reflects stigma among psychiatric clinicians regarding treatment of OUD and lack of education around evidence-based care for OUD with MOUD. Improving treatment of OUD and mental health are critically entwined in those with co-morbid disease, by expanding MOUD access within psychiatric hospitals we have the opportunity to save lives and improve mental health.  

Learning Objectives

1. Describe the availability of medications for opioid use disorder within psychiatric hospitals

Keywords

• Medicatoin for Opioid Use Disorder
• Psychatric Hospital
• Methadone
• Buprenorphine
• Opioid Use Disorder

Presenter
Srinivas Muvvala, MD

 

Dr. Muvvala is an Associate Professor of Psychiatry and Associate Program Director for the Addiction Psychiatry Fellowship at the Yale School of Medicine and the Medical Director of the Substance use & Addiction Treatment Unit (SATU) at the Connecticut Mental Health Center. He oversees the educational, clinical and research programs at SATU.

Dr. Muvvala received multiple awards for his teaching including the American Psychiatric Association’s Irma Bland award for resident education in Psychiatry for 2021.

His clinical and research interests are in investigating and disseminating optimal pharmacotherapies for the treatment of substance use disorders and in providing integrated treatment for individuals with comorbid substance use, medical and psychiatric disorders.

He is the consultant and advisor to the Department of Mental Health and Addiction services of Connecticut and the chair of research for the Connecticut’s Opioid Settlement Advisory Committee. He is a member in key committees at various national organizations including ABPN, AAAP and ACGME. 

Co-Authors: Shawn M. Cohen, MD, Tamara Beetham, David A. Fiellin, MD

Summary
Substance use disorder (SUD) has increased worldwide, especially in the United States, with millions struggling with drug and alcohol problems. Substance use (SU) can lead to significant adverse health outcomes along with stigmatization in healthcare settings. Shame plays a complex role in the development and mitigation of developing substance use problems, influenced by cultural contexts such as dignity, face, and honor. Using a cross-sectional survey methodology, we assess demographics, shame, self-esteem, and substance use history. Participants were recruited from a multicultural metropolitan area in Michigan with a relatively large Middle Eastern population, 15% of participants were immigrants.

The primary goal of this study was to investigate the impact of factors such as shame and SU in individuals in minority and immigrant communities. Specifically, we aimed to identify and compare rates of shame among immigrants and minorities versus non-immigrants and non-minorities with substance problems. We found that Caucasians and U.S.-born individuals are significantly more likely to report poor self-esteem and screen positive for probable SUD compared to non-Caucasians and foreign-born individuals. One study found higher rates of SUDs in foreign-born, although makes no mention of shame. It further suggests that first-generation immigrants have markedly increased SUD prevalence than second-generation immigrants and U.S.-born. Our findings may suggest that lower levels of internalized shame have led to decreased prevalence of SUD amongst minority and immigrant communities, although it could also mean that decreased SU resulted in less subsequent shame. Based on all the respondents who had poor self-esteem reporting that shame existed before SU, the former hypothesis seems more likely. These unexpected findings challenged our initial predictions, which were based on the body of research that suggests that immigrants experience higher levels of hardships such as: food security, bill-paying and finances, housing, ownership of durable consumer goods, and neighborhood problems. When considering immigrant struggles, one might think the gap in assimilation and higher level of social and economic hardships might predict more difficulty in struggling with feelings of shame and SU, although this was not the case. It is also possible that ISS does not accurately capture non-Western concepts of shame. It is also possible that our results reflect that Middle Easterners in the U.S. represent a subset of Middle Easterners who had traits that made them more likely to immigrate and less likely to experience shame or use substances (e.g., financial resources, problem-solving skills). A perspective that could possibly explain lower shame among foreign-born is that perhaps these individuals who have uprooted their lives and dealt with the difficulties of immigrating have built emotional resilience and protective mindsets. This idea is supported by a study showing immigrants are less likely to self-select in “health-risk behaviors”. This sentiment has been coined the “healthy immigrant effect” as a growing number of studies have arrived at similar conclusions related to healthier behavior and lower chronic health conditions. Finally, another potential explanation is that lack of a solid citizenship status could play a role in the fear of losing U.S. residence due to legal repercussions associated with SU.

We believe the lack of current research accounting for shame, culture and SU warrants further investigation, including confirmation of results, determination of correlation vs. causation, generalizability to other populations, and to find effective screening and interventions. Identifying the factors associated with SUD may allow clinicians and societies to address them before SUD develops and mitigate problems once they occur. Additionally, by studying psychosocial factors in SUD, we hope to increase recognition of experienced shame, and the understanding of culture and its effects on mental health. Lastly, the investigations could illuminate issues in communities originating from honor and shame cultures, in which the research has been scarce. 

Background
Alcohol and drug use have become increasingly prevalent around the world and particularly in the United States. In 2020, among adults aged 18 or older, 52.9 million had any mental disorders and, of those, 17 million had a substance use disorder (SUD). Additionally, among people aged 12 years or older, 21.4% or 59.3 million people used illicit drugs in the past year. Substance use (SU) is associated with poorer health outcomes such as suicide, mood disorders, increased risk of hospitalization, and death. While healthcare needs are higher, stigma in healthcare can make SU difficult to treat.

Shame has been hypothesized to play a role in the development and maintenance of SU. A systemic review of 42 studies attempted to identify the relationship between SU and shame, with some studies suggesting shame predicted higher subsequent substance use and others predicting lower subsequent substance use. The mixed results indicate that shame was reliably associated with SU but can serve both adaptive and maladaptive functions in its development.

Culture is known to influence shame. Cultural norms, goals, relationships, and interactions with others help establish which social outcomes are valued and how emotions are experienced. For instance, western European countries have been identified as “dignity cultures,” many eastern Asian countries have been identified as “face cultures,” and many Latin American and Middle Eastern countries have been identified as “honor cultures”. Dignity cultures are thought to emerge  from individuals guided by strong organizations and institutions who operate independently and autonomously. Face cultures are thought to emerge from individuals committed to work together in protecting social harmony in the context of a hierarchical system. Honor cultures are thought to emerge from harsh and competitive environments with high levels of status inequality. Self-worth in honor cultures is determined by the extent of which the individual believes themselves to be an honorable person, but only if that belief is reinforced by the views and image of others.

Though there is research connecting SU to shame, and connecting shame to culture, there is a paucity of research looking at all three concepts. We predict that, in some cultures, shame and negative perception from others can have negative impact on one’s self-worth, potentially leading to increased risk for SU. Therefore, our study seeks to explore how shame interacts and correlates with SU, particularly in immigrant and minority communities.

Identifying the factors associated with SUD may allow clinicians and societies to address them before SUD develops and mitigate problems once they occur. Addressing the mindset of those in a shame and honor culture and those who interact with them may be significant approach to help others recover and live their best life. 

Methods
In this cross-sectional study, 33 participants were recruited from locations to include participants from various backgrounds with and without substance use problems. Recruitment methods included posting flyers, emailing survey links, and word of mouth. An integrated survey was used to assess demographics, shame, self-esteem, and SU history. Shame and self-esteem were assessed using the Internalized Shame Scale (ISS), a reliable and validated instrument in clinical and non-clinical populations, including substance-dependent populations. To assess SU, the study utilized investigator-design queries about various substance-related problems and perceived shame before and after SU. Probable substance use disorder was assessed using the Two-Item Conjoint Screen (TICS) for Alcohol and Other Drug Problems. Variables were assessed using T-tests or One-Way Analysis of Variance and Fisher Exact Tests. 

Results
Probable SUD was significantly associated with Caucasians (p=0.005), U.S. birth (p=0.008), cannabis problems (p=0.01), nicotine problems (p=0.02), and poor self-esteem (p=0.03). High shame was significantly associated with cannabis problems (p=0.01), wanting to cut down on SU in the last 12 months (p=0.04), alcohol problems (p=0.05), and trended toward being significantly associated with pre-SU shame (p=0.0525). Poor self-esteem was significantly associated with wanting to cut down on SU in the last 12 months (p=0.0005), females and non-binary genders (p=0.01), U.S. births (p=0.01), pre-SU shame (p=0.01), nicotine problems (p=0.03), probable SUD (p=0.04), and Caucasians (p=0.05). Multiple significant associations related to SU and shame were found. Contrary to our expected findings, being Caucasian and U.S.-born were both significantly associated with both Probable SUD and poor self-esteem. 

Conclusion
We found multiple significant associations related to SU and shame. Contrary to our expectations, being Caucasian and U.S.-born were both significantly associated with both Probable SUD and poor self-esteem (a subcomponent of shame). We hope future studies will better elucidate how shame and culture interact to affect SU, that there may be identifiable targets and perhaps effective interventions. Understanding the etiology of SU, and the role shame plays, could lead to early and targeted interventions that help mitigate the development of SUDs and improve treatment outcomes.   

Scientific Significance
Our findings may suggest that lower levels of internalized shame have led to decreased prevalence of SUD amongst minority and immigrant communities. It could also mean that decreased SU resulted in less subsequent shame. Based on the respondents who had poor self-esteem reporting that shame existed before SU, the former hypothesis seems more likely. These unexpected findings challenged our initial predictions, which were based on the body of research that suggests that immigrants experience higher levels of hardships. We believe the lack of current research accounting for shame, culture and SU; our use of validated measures; and significant findings make our study a worthy contribution to the literature that warrants confirmation of results, determination of correlation vs. causation, and to find effective screening and interventions. 

Learning Objectives

1. Identify and compare levels and rates of shame in those among immigrants and minorities versus non-immigrants and non-minorities with substance problems. 
2. Identify and compare levels and rates of self-esteem in those among immigrants and minorities versus non-immigrants and non-minorities with substance problems.
3. Identify and compare rates and type of probable substance use disorder in those among immigrants and minorities versus non-immigrants and non-minorities.

Keywords

• Substance Use
• Shame
• immigrants
• Ubstance Use Disorders
• Minorities

Presenter
Zane Alroshood

 

Hello! My name is Zane Alroshood, 4th year medical student interviewing for psychiatry residency. My interests are in addiction medicine, psychotherapy, and interventional psychiatry. I believe my most valuable gifts and experiences are the stories I hear from those I interact with. 

Co-Authors: Jeffrey Guina, Hassan Barade

Summary
Substance use disorder (SUD) has increased worldwide, especially in the United States, with millions struggling with drug and alcohol problems. Substance use (SU) can lead to significant adverse health outcomes along with stigmatization in healthcare settings. Shame plays a complex role in the development and mitigation of developing substance use problems, influenced by cultural contexts such as dignity, face, and honor. Using a cross-sectional survey methodology, we assess demographics, shame, self-esteem, and substance use history. Participants were recruited from a multicultural metropolitan area in Michigan with a relatively large Middle Eastern population, 15% of participants were immigrants.

The primary goal of this study was to investigate the impact of factors such as shame and SU in individuals in minority and immigrant communities. Specifically, we aimed to identify and compare rates of shame among immigrants and minorities versus non-immigrants and non-minorities with substance problems. We found that Caucasians and U.S.-born individuals are significantly more likely to report poor self-esteem and screen positive for probable SUD compared to non-Caucasians and foreign-born individuals. One study found higher rates of SUDs in foreign-born, although makes no mention of shame. It further suggests that first-generation immigrants have markedly increased SUD prevalence than second-generation immigrants and U.S.-born. Our findings may suggest that lower levels of internalized shame have led to decreased prevalence of SUD amongst minority and immigrant communities, although it could also mean that decreased SU resulted in less subsequent shame. Based on all the respondents who had poor self-esteem reporting that shame existed before SU, the former hypothesis seems more likely. These unexpected findings challenged our initial predictions, which were based on the body of research that suggests that immigrants experience higher levels of hardships such as: food security, bill-paying and finances, housing, ownership of durable consumer goods, and neighborhood problems. When considering immigrant struggles, one might think the gap in assimilation and higher level of social and economic hardships might predict more difficulty in struggling with feelings of shame and SU, although this was not the case. It is also possible that ISS does not accurately capture non-Western concepts of shame. It is also possible that our results reflect that Middle Easterners in the U.S. represent a subset of Middle Easterners who had traits that made them more likely to immigrate and less likely to experience shame or use substances (e.g., financial resources, problem-solving skills). A perspective that could possibly explain lower shame among foreign-born is that perhaps these individuals who have uprooted their lives and dealt with the difficulties of immigrating have built emotional resilience and protective mindsets. This idea is supported by a study showing immigrants are less likely to self-select in “health-risk behaviors”. This sentiment has been coined the “healthy immigrant effect” as a growing number of studies have arrived at similar conclusions related to healthier behavior and lower chronic health conditions. Finally, another potential explanation is that lack of a solid citizenship status could play a role in the fear of losing U.S. residence due to legal repercussions associated with SU.

We believe the lack of current research accounting for shame, culture and SU warrants further investigation, including confirmation of results, determination of correlation vs. causation, generalizability to other populations, and to find effective screening and interventions. Identifying the factors associated with SUD may allow clinicians and societies to address them before SUD develops and mitigate problems once they occur. Additionally, by studying psychosocial factors in SUD, we hope to increase recognition of experienced shame, and the understanding of culture and its effects on mental health. Lastly, the investigations could illuminate issues in communities originating from honor and shame cultures, in which the research has been scarce. 

Background
In response to the escalating opioid crisis, the State Opioid Response (SOR) grants, initiated in 2018, have significantly influenced opioid use disorder (OUD) treatment strategies across the United States. Tennessee, a Medicaid non-expansion state severely impacted by the opioid epidemic, has utilized these grants to implement a Hub-and-Spoke (H&S) model. This model aims to streamline and enhance OUD treatment by providing a seamless continuum of care from acute treatment settings to community-based recovery support. Despite the documented efficacy of H&S models, there is limited understanding of their performance in Medicaid non-expansion states like Tennessee, where resources are primarily allocated to direct care rather than expanding access. In these settings, the challenges faced by uninsured patients or those relying on SOR grants may differ significantly from those of insured patients, particularly concerning treatment success and integration into long-term recovery programs.

The Vanderbilt University Medical Center (VUMC) serves as the central hub for the middle Tennessee region, offering a comprehensive range of addiction services, including an interdisciplinary addiction consultation service, an inpatient co-occurring disorder-focused psychiatric unit, and an intensive outpatient program. The VUMC Bridge clinic, established in 2019, provides critical transitional care for individuals with OUD discharged from acute care settings, offering comprehensive behavioral health treatment regardless of insurance status. Uninsured patients are enrolled in the SOR program, with many transitioning to the Vanderbilt Recovery Clinic (VRC) for longitudinal outpatient care. This study evaluates the care outcomes of OUD patients at the VRC, comparing those funded through the SOR grant to those with traditional health insurance. By examining the impact of different funding strategies on patient outcomes, continuity of care, and overall system performance, the study aims to inform future health policies and practices, optimize OUD treatment, and guide resource allocation in the ongoing battle against the opioid epidemic.

Methods
This retrospective cohort study evaluates outcomes of patients receiving medications for opioid use disorder (OUD) at a longitudinal outpatient co-occurring disorder clinic from October 18, 2019, to August 1, 2023. Participants were divided into two groups: those funded by the State Opioid Response (SOR) grant and those with traditional health insurance. Key measures included demographics, baseline clinical characteristics, treatment engagement, adherence, substance use outcomes, and acute care utilization. A generalized linear model with covariate balancing propensity score weighting was used to adjust for differences between groups. Additionally, a parallel analysis was conducted on a sub-cohort of patients with prior Bridge clinic engagement to evaluate the impact of initial treatment exposure on long-term outcomes. 

Results
Of the 524 patients, 118 were SOR grant-funded and 406 traditionally insured. The SOR-funded group had a higher proportion of male patients and increased rates of cannabis and  stimulant use disorders, PTSD, and HCV infection. They also had significantly more encounters at the transitional Bridge clinic before transferring to the VRC. Among all patients, there were no statistically significant differences between SOR-funded and traditionally insured patients in terms of treatment frequency, attrition, retention, return to opioid use, methamphetamine co-use, emergency department visits, or hospitalizations. In the sub-cohort with prior Bridge clinic engagement, SOR-funded patients had more frequent VRC encounters in the first 180 days but also experienced higher rates of return to opioid use, methamphetamine co-use, and longer hospital stays compared to traditionally insured patients. 

Conclusion
While patients funded by SOR grant generally exhibit comparable OUD care outcomes to those funded by traditional payors, notable disparities emerge for those with prior Bridge clinic engagement. In this subgroup, SOR-funded patients experience poorer outcomes in substance use and hospitalization length, suggesting that SOR funding may be insufficient for patients with complex needs transitioning from acute care. These findings highlight the limitations of SOR funding and the necessity for expanded access to comprehensive care and enhanced support services to better address the complexities of addiction recovery. 

Scientific Significance
The findings underscore the nuanced impact of funding sources on opioid use disorder (OUD) treatment outcomes. While SOR funding may improve treatment engagement, it may be insufficient for patients with complex needs transitioning from acute care settings. The study reveals critical gaps in the continuum of care for these patients, emphasizing the need for enhanced and integrated support services. These insights are crucial for informing future health policies and optimizing resource allocation to improve long-term outcomes in OUD treatment, particularly in Medicaid non-expansion states. By highlighting these disparities, the research contributes to a deeper understanding of how funding mechanisms can influence the effectiveness of addiction treatment programs.  

Learning Objectives

1. Identify the differences in patient engagement, substance use, and acute care utilization outcomes between grant-funded and traditionally insured patients. 
2. Appreciate the impact of funding sources on patient care and long-term recovery outcomes in a Medicaid non-expansion state. 
3. Evaluate the effectiveness of the H&S model in a Medicaid non-expansion state. 

Keywords

• Opioid Treatment Programs
• Health Services Research
• Medicaid Coverage Gap
• State Opioid Response

Presenter
Thao Le, MD, PhD

  

Psychiatry Resident at MGH/McLean
Vanderbilt MSTP (2016-2024)

Co-Authors: Thomas Reese, PhD, Andrew Wiese, David Marcovitz, MD

Summary
Cannabis use has become increasingly prevalent in the United States, raising significant public health concerns and highlighting the need for targeted treatment services. As legalization spreads, it is crucial to understand the predictors of treatment admissions for cannabis use to develop effective interventions. Previous research has identified risk factors for substance use disorders in general, but comprehensive analyses specific to cannabis are limited. This study aims to fill this gap by examining a wide range of predictors, including sociodemographic characteristics, patterns of cannabis use, comorbid conditions, and referral sources, using a large national dataset.

The study's objectives are to identify demographic, socioeconomic, and behavioral predictors of treatment admissions for cannabis use in the United States and to assess the impact of early cannabis use, frequency of use, route of administration, comorbid mental health and substance use disorders, and referral sources on the likelihood of treatment admission. A retrospective analysis was performed using the 2020 Treatment Episode Data Set Admissions (TEDS-A), representing admissions to all publicly funded substance abuse treatment facilities. The focus was on admissions where cannabis was the primary substance for treatment. Univariate analysis identified the prevalence and characteristics of these admissions, and multivariable logistic regression analysis identified predictors associated with cannabis treatment admission.

Results showed that out of 1,545,201 treatment admissions, 9.1% were for cannabis use as the primary substance. Males had a higher percentage of treatment admissions for cannabis use compared to females (11.2% vs. 9.9%; p<0.0001). A significant proportion of young adults (12-24 years) reported treatment admissions for cannabis use compared to other substances (41.6% vs. 8.8%; p<0.0001). African Americans were more likely to report treatment admissions for cannabis use than for other substances (34.4% vs. 16.8%; p<0.0001). Cannabis treatment admissions had the highest prevalence of alcohol being reported as a secondary (25.0% vs. 7.0%; p<0.0001) and tertiary substance (4.7% vs. 3.7%; p<0.0001). 

Adjusted regression analysis revealed several predictors for cannabis treatment admission. Key sociodemographic predictors included being aged 12-24 years (Adjusted OR: 5.7; 95% CI: 4.9-6.7; p<0.0001), African American race (aOR: 4.0; 95% CI: 3.9-4.1; p<0.0001), male gender (aOR: 1.4; 95% CI: 1.3-1.4; p<0.0001), having a Bachelor’s degree or higher (aOR: 1.5; 95% CI: 1.4-1.6; p<0.0001), full-time employment (aOR: 1.4; 95% CI: 1.4-1.5; p<0.0001), and independent living (aOR: 2.3; 95% CI: 2.2-2.4; p<0.0001). Substance use characteristics included age at first cannabis use before 11 years (aOR: 73.2; 95% CI: 68.0-79.0; p<0.0001), daily cannabis use (aOR: 1.3; 95% CI: 1.2-1.4; p<0.0001), previous treatment episodes (aOR: 0.7; 95% CI: 0.7-0.8; p<0.0001), smoking as the route of administration (aOR: 199.0; 95% CI: 190.4-208.0; p<0.0001) compared to oral use, and comorbid mental health and substance use disorders (aOR: 1.3; 95% CI: 1.2-1.4; p<0.0001). Educational referrals had the highest odds of treatment admission (aOR: 7.4; 95% CI: 6.4-8.5; p<0.0001), followed by employer referrals (aOR: 6.7; 95% CI: 5.8-7.7; p<0.0001).

In conclusion, the study found that 9.1% of treatment admissions were for cannabis use, with higher rates among males, young adults (12-24), and African Americans. Alcohol was the most commonly reported secondary and tertiary substance. Significant predictors for cannabis treatment admissions included early initiation, daily use, smoking, and comorbid mental health disorders. Sociodemographic factors such as male gender, higher education, full-time employment, and independent living also increased the odds of admission. Educational and employer referrals, along with non-intensive outpatient services, were strongly associated with treatment admissions. These findings suggest the need for targeted interventions, tailored treatment approaches, and enhanced education on cannabis risks, as well as policy adjustments to address the specific needs of high-risk groups and improve treatment outcomes. The study's findings underscore significant public health concerns and can inform clinical practices, guide research on tailored interventions, and shape policies to enhance prevention, early intervention, and treatment strategies for cannabis use disorders. 

Background
Cannabis use has become increasingly prevalent in the United States, leading to significant public health concerns and a growing need for treatment services. As cannabis legalization spreads across various states, understanding the demographic, socioeconomic, and behavioral predictors of treatment admissions for cannabis use is crucial for developing targeted interventions. Previous studies have highlighted specific risk factors associated with substance use disorders, but comprehensive analyses focusing specifically on cannabis are limited. Identifying the predictors of treatment admissions for cannabis use can inform healthcare providers, policymakers, and educators in creating effective prevention and treatment strategies. This study aims to fill this gap by examining a wide range of predictors, including sociodemographic characteristics, patterns of cannabis use, comorbid conditions, and referral sources, using a large national dataset. 

Methods
We performed a retrospective analysis of Treatment Episode Data Set Admissions (TEDS-A) 2020 data that nationally represents admissions to all private and public substance abuse treatment facilities that receive public funding. Our study included all treatment admissions where cannabis was self-reported as the primary substance for treatment purposes. We performed univariate analysis to identify the prevalence and characteristics of treatment admissions for cannabis use using Pearson’s chi-square test for categorical variables and an unpaired t-test for continuous variables. Multivariable logistic regression analysis was performed to identify the predictors associated with treatment admission for cannabis use. 

Results
Out of 1,545,201 admissions, 9.1% were for cannabis use as the primary substance. Males had higher admission rates than females (11.2% vs. 9.9%). Participants aged 12-24 (41.6% vs. 8.8%) and African Americans (34.4% vs. 16.8%) had a higher prevalence of admissions for cannabis use. Alcohol was the most prevalent secondary (25.0% vs. 7.0%) and tertiary substance (4.7% vs. 3.7%). Key predictors included age 12-24 (aOR: 5.7), African American race (aOR: 4.0), male gender (aOR: 1.4), higher education (aOR: 1.5), full-time employment (aOR: 1.4), independent living (aOR: 2.3), early use (aOR: 73.2), daily use (aOR: 1.3), smoking (aOR: 199.0), and comorbid disorders (aOR: 1.3). Educational (aOR: 7.4) and employer referrals (aOR: 6.7) were significant predictors, as was ambulatory non-intensive outpatient service (aOR: 8.3). 

Conclusion
Out of 1,545,201 treatment admissions, 9.1% were for cannabis use as the primary substance. Males, young adults (12-24), and African Americans showed higher treatment admission rates for cannabis use. Alcohol was the most commonly reported secondary and tertiary substance. Predictors for cannabis treatment admissions included early age at first use, daily use, smoking, and comorbid mental health disorders. Sociodemographic factors such as male gender, higher education, full-time employment, and independent living also increased the odds. Educational and employer referrals, as well as non-intensive outpatient services, were strongly associated with admissions. These findings suggest a need for targeted interventions, tailored treatment approaches, enhanced education on cannabis risks, and policy adjustments to address the specific needs of these high-risk groups and improve treatment outcomes. 

Scientific Significance
The study's findings reveal critical sociodemographic and behavioral predictors for cannabis use treatment admissions, highlighting significant public health concerns. Higher admission rates among males, young adults, and African Americans indicate targeted intervention needs. The strong association between early cannabis initiation and treatment admissions underscores the importance of early prevention efforts. The frequent co-occurrence with alcohol suggests integrated treatment approaches. The predictive value of education,  employment, and referral sources emphasizes the role of socio-environmental factors in treatment accessibility and outcomes. These results can inform clinical practices, guide research on tailored interventions, and shape policies to enhance prevention, early intervention, and treatment strategies for cannabis use disorders. 

Learning Objectives

1. The first objective of this study is to identify the demographic, socioeconomic, and behavioral predictors of treatment admissions for cannabis use in the United States. 
2. The second objective of this study is to assess the impact of early cannabis use, frequency of use, route of administration, comorbid mental health and substance use disorders, and referral sources on the likelihood of treatment admission.

Keywords

• Cannabis
• Treatment
• Predictive Modeling

Presenter
Saral Desai, MD

  

Saral Desai, MD, is a certified clinical research professional and a PGY-2 psychiatry resident physician at Tower Health/Drexel University College of Medicine Program in Philadelphia. He is passionate about research in psychiatry and actively involved in research on topics related to substance use disorders, public health, and health risk behaviors. As a resident, he continues to teach and inspire medical students and residents to join him in his research endeavors.

Co-Authors: Raven Simmons, Jessica Kuo, Arundhati Nittur, Tara Tadimalla, Samik Patel, Wei Du, MD