Substance abuse treatment: cultural barriers in the Asian-American community.

Honoring Asian diversity by collecting Asian subpopulation data in health research.

Reliability and Validity of the Substance Abuse Outcomes Module

An Opportunity for Parity: Health Care Reform Vis-à-Vis Behavioral Health and Substance Abuse Treatment

Symptoms characteristic of autism spectrum disorder were initially believed to protect individuals with autism spectrum disorder from developing substance abuse. However, recent studies suggest that up to 36% of individuals with autism spectrum disorder may have a co-occurring issue with substance abuse. In addition, substance abuse may worsen the difficulties with daily functioning some individuals with autism spectrum disorder experience. It is important to understand occurrence rates, and risk, protective and positive treatment factors of co-occurring autism spectrum disorder and substance abuse in order to promote the best possible support for this special population. This review aimed to find and synthesize evidence regarding risk, protective and treatment factors, and determine a general prevalence rate of co-occurring autism spectrum disorder and substance abuse from all studies on substance use and abuse in individuals with autism spectrum disorder. The review also aimed to assess study quality and identify a diagnostic measure for substance abuse in individuals with autism spectrum disorder. Twenty-six studies on substance use and abuse in autism spectrum disorder were included in the review. The rates of substance abuse among those with autism spectrum disorder identified by included studies ranged from 1.3% to 36%, but due to large differences in study methods, a general prevalence rate could not be determined. Risk and protective factors, recognized in the general population, such as familial substance abuse and co-occurring mental health issues, and factors which may be more likely to occur in individuals with autism spectrum disorder, such as limited social resources and low sensation-seeking, were identified. No diagnostic measures specific to individuals with autism spectrum disorder and substance abuse were identified. This review identified only one exploratory study on an adapted intervention for co-occurring autism spectrum disorder and substance abuse. However, there were many methodological challenges in this study that limit the conclusions that can be drawn from the data. More research, using consistent methods, is needed to understand risk and protective factors and to determine the prevalence of substance abuse among individuals with autism spectrum disorder. The potential for co-occurring autism spectrum disorder and substance abuse should be considered by professional working in both autism spectrum disorder and substance abuse services, as finding suggests substance abuse is possible among individuals with autism spectrum disorder and may occur more frequently than previously believed. In addition, autism spectrum disorder and substance abuse service providers should be sensitive to specific risk and protective factors identified by the review that may impact substance abuse course and outcomes.

Youth drug abuse1 of the kind that persists beyond the experimentation phase is a severe problem worldwide (United Nations Office on Drugs and Crime (UNODC), 2010). Abuse of non-opioid drugs such as cannabis, amphetamine and cocaine is strongly associated with a broad range of negative health implications such as traffic accidents, sexually transmitted diseases, mental problems and suicide as well as social problems including poor academic achievement, delinquency and violent behavior (Deas & Thomas, 2001; Essau, 2006; Rowe & Liddle, 2006; ONDCP, 2000; Shelton, Taylor, Bonner & van den Bree, 2009; Nordstrom & Levin, 2007; Lynskey & Hall, 2000). While cannabis, amphetamine, cocaine and other non-opioid drugs remain illegal in most countries, surveys indicate widespread prevalence. In the US, 25.5 percent of 12th-grade students report having used an illicit drug (any kind) within the last month (Johnston, O'Malley, Miech, Bachman & Schulenberg, 2014). In Canada, 21 percent of 15–24 year olds report having used of some kind of illicit drugs within the last year (Health Canada, 2011). In Australia, seven percent 12–17 year olds report using some kind of drug within the last month (White & Smith, 2009). The European Monitoring Centre for Drugs and Drug Addiction has found that that within Europe prevalence differs significantly from country to country but that overall around a quarter of Europeans report having used some kind of illicit drug in their lifetime (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2013). The prevalence of specific kinds of illicit drug abuse varies significantly, with cannabis generally being the most commonly used drug. In the US, 22.7 percent of 12th-grade students report having used marijuana/hashish (types of cannabis), 4.1 percent amphetamine, and 1.1 percent cocaine during the last 30 days before the National Survey on Drug Use conducted in 2013 (Johnston et al., 2014). The European Drug Report of 2013 indicates that 11.7 percent of the 15 to 34 year-olds in Europe have used cannabis, 1.3 percent amphetamine, and 1.9 percent used cocaine during the last year (EMCDDA, 2013). Although not all young drug users progress to severe dependence, some do and may therefore require treatment (see e.g. Crowley, Macdonald, Whitmore & Mikulich, 1998). Research draws attention to the significant gap between the number of young people classified as in need of treatment and the number of young people who actually receive such treatment (SAMHSA, 2010; National Survey on Drug Use and Health (NSDUH), 2007). In the US, for example, 7.2 million people aged 12 or older are classified as needing treatment for illicit drug abuse, but only 1.4 million of these young people actually receive treatment at a specialty facility for an illicit drug abuse problem (SAMHSA, 2011). The treatment usually provided to young people is delivered in outpatient settings. Accordingly, 90 percent of the 89,521 clients under age 18 registered in substance abuse treatment in 2012 by SAMHSA were in outpatient treatment, which is the same proportion as the total treatment population (SAMHSA, 2013). Equal proportions of the clients under age 18 were enrolled in facilities with a primary focus on substance abuse treatment and in facilities whose primary focus were provision of a mix of mental health and substance abuse treatment services; this differs from the total treatment population as youth tend to be treated in dual focus facilities more often than adults (SAMHSA, 2013). Cognitive-behavioral therapy and motivational interviewing are specific therapeutic approaches that are used at least sometimes by most (respectively 91 and 87 percent) treatment facilities (SAMHSA, 2013). There is growing public concern about the effectiveness and high costs of available treatments for young people, and the high rates of treatment dropout and post-treatment relapse to drug abuse (Austin, Macgowan & Wagner, 2005; Najavits & Weiss, 1994; Stanton & Shadish, 1997). While relapse must be acknowledged as an expected part of any treatment process targeting individual drug use, efforts should be made to make treatment as attractive, accessible and relevant as possible for young people in order to minimize the risk of unwarranted dropout and continuous relapse (Simmons et al., 2008; National Institute on Drug Abuse (NIDA), 2009). Furthermore, the services provided should be empirically supported to increase the likelihood that (a) treatment will be successful, and (b) public spending supports the interventions that are the most effective. Researchers point to the fact that many research projects have empirically validated different types of treatment approaches as effective for young drug users (e.g. Rowe & Liddle, 2006; Waldron, Turner & Ozechowski, 2006; Williams, Chang & Addiction Centre Adolescent Research Group, 2000; Austin et al., 2005). The effectiveness, however, depends upon the interplay between a specific intervention and individual factors such as gender, ethnicity, family composition, co-morbidity and history of drug abuse (Brannigan, Schackman, Falco & Millman, 2004; Hawkins 2009; Horsfall, Cleary, Hunt & Walter 2009). For example, research suggests that treatment outcomes of a specific program such as Functional Family Therapy may vary for different ethnic groups (Hops, Ozechowski, Waldron, Davis, Turner, Brody & Barrera, 2011; Flicker, Waldron, Turner, Brody & Hops, 2011). The current challenge in the field of substance abuse treatment for young people is therefore to establish not only what works best but also what works for different subgroups. In terms of treatment types, there is some documentation of promising individually-based cognitive and motivational therapies (Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001; Galanter & Kleber, 2008). Family-based approaches on the other hand may be equally effective. Family therapy encompasses a range of different interventions with varying theoretical sources, including behavioral and cognitive behavioral theory, structural and strategic family theory, and family systems theory (Williams et al., 2000; Austin et al., 2005). Some reviews have suggested that these family-based therapies are superior to individual-based programs in reducing youth drug abuse (Williams et al., 2000; Lipsey, Tanner-Smith & Wilson, 2010; Waldron, 1997). Young people with persistent drug abuse have unique needs due to their particular cognitive and psychosocial development. Young people are especially sensitive to social influence, with family and peer groups being highly influential. Youth drug treatments which facilitate positive parental and peer involvement, and which integrate other systems in which the young person participates (such as schools, social services, and justice authorities) are thus key to reducing drug abuse by young people (NIDA, 2009). A number of studies and reviews have showed positive results for family therapies in general, but there is a need to synthesize individual study results for specific family therapies to determine whether and to what extent specific family therapy interventions work for young drug abusers (Williams et al., 2000; Austin et al., 2005; Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001). This review is concerned specifically with Functional Family Therapy (hereafter FFT) (Alexander & Parsons, 1973; Alexander & Parsons, 1982; Rowe & Liddle, 2003), as aggregated evidence for the effects of this approach is lacking. The review will seek to clarify the effects of the FFT program for relevant groups of young people aged 11–21, and will focus on young people enrolled in treatment for drug abuse, irrespective of how their problem is defined. Enrolment in treatment is taken to imply that the severity of the young person's drug abuse has compelled a close, significant adult (for example, teacher, parent, social services, or school counselor) to demand that the young person enters treatment. FFT is an intervention offered as an outpatient treatment2 to young people age 11–21 that are living with their families. This review focuses solely on non-opioid drug abuse3, and is one in a series of reviews on manual-based family therapy interventions for young people in treatment for non-opioid drug abuse4. Functional Family Therapy (FFT) is a short-term, manual-based, behaviorally oriented family therapy program for young people with behavior problems such as drug abuse, juvenile delinquency and violence. Delivered in an outpatient setting, it aims to help young people and their families by improving family interactions and relationship function by addressing dysfunctional individual behavior (Sexton & Alexander, 2000; Sexton & Turner, 2011). In an FFT program, the therapist provides intensive family therapy in an attempt to change the patterns of family interaction that are contributing to the problem behavior and to help family members develop specific skills in, for example, communication, conflict resolution, problem solving, and effective parenting. After the desired behavioral change has been achieved within the family, the therapist helps the family generalize changes to other situations and settings, such as school, community, and peers, and identifies support that can help to maintain the progress made (Sexton & Alexander, 2003; Onedera, 2006). As with many other forms of family therapy, FFT targets young people and their families as a system. As such, it recognizes the important role of the family system in the development and treatment of young people's drug abuse problems (Ozechowski & Liddle, 2000). While a specific FFT intervention may focus on improving specific problems such as drug abuse, the FFT approach in itself adds a broader view of the change process and clinical outcomes by switching from an individual problem focus to a relational perspective. The intervention is designed to help families recalibrate their interaction patterns and improve family relations, and through this achieve individual goals such as decreased drug abuse (Alexander, Waldron, Robbins & Neeb, 2013). FFT was developed in the late 1960s and early 1970s (Alexander & Parsons, 1973) with the model described in full by Alexander and Parsons in the early 1980s (Alexander & Parsons, 1982). It was developed to serve diverse populations of under-served and at-risk adolescents and their families because these populations lacked resources, were difficult to treat, and were often perceived by professionals as lacking the motivation for change. The founders of FFT realized that successful treatment of these populations required service providers who were sensitive to the needs of these diverse families, who were competent to work with them, and who understood why the families had traditionally resisted treatment (Sexton & Alexander, 2003). The development of the FFT program has continued, and the therapy has been refined in response to the results of research and the experiences from successful implementation (Alexander & Robbins, 2010). In a systematic review conducted by Austin, Macgowan & Wagner (2005), FFT appeared as one of five interventions identified as consistent with the majority of guidelines for effective treatment for adolescents with substance abuse. Austin et al. (2005) also note, however, that there is some inconsistency in the research on outcomes of FFT and that long-term follow-up assessment is needed. In a meta-analytical study, Waldron & Turner (2008) synthesized findings from 17 studies evaluating outpatient treatments for substance-abusing youth, including several therapy models, among them FFT, other family therapy approaches, group CBT, individual CBT and minimal treatment conditions. Waldron & Turner (2008) found that the effect size associated with reductions in drug abuse was significantly larger for family therapy relative to the minimal treatment condition, but the meta-analysis did not establish one of the treatment approaches as clearly superior to any other in terms of treatment effectiveness for substance-abusing youth. FFT is derived from both family system theory (Alexander & Parsons, 1973) and cognitive behavioral theory and techniques (Alexander & Robbins 2010). The therapy focuses on family functioning, and is thus based on the premise that both positive and negative behavior can have a direct influence, and are influenced by multiple relational systems (Alexander & Sexton, 2002; Sexton & Alexander 2000). It assumes that young people's problem behavior can serve a function within the family. Family members develop ways of interacting that help them meet their relational needs for closeness or distance, but these patterns of interacting may also create or maintain behavioral problems. When changes are made in how the family interacts (by, for example, improving communication, problem-solving, and parenting skills), behavioral problems will be resolved. Interventions must take into account the needs of each family member and be tailored to the family's unique risk and protective factors (Alexander & Sexton, 2002; Sexton & Alexander, 2003; Alexander et al., 2013). While FFT is established as a distinctly unique approach, it has not emerged in a vacuum and is related to other current treatment approaches. Accordingly, Calley (2011) states that one of the most striking elements of the functional family therapy approach is its similarity to other therapeutic models, such as multisystemic family therapy, motivational enhancement therapy and solution-focused brief therapy. She emphasizes that this is not a deficit of the FFT model but rather a reminder of the evolutionary nature of the theories informing psychotherapy in general. Some of the characteristics that make FFT stand out are the emphasis on relational functions (hence the title Functional Family Therapy), the level of implementation of detailed treatment manuals and protocols for training and supervision, as well as the distinctive phase model (Alexander et al., 2013). Furthermore, FFT is a multi-systemic treatment focusing on the multiple domains and systems of which the adolescent is part, such as the community, school and the juvenile justice system (Sexton & Alexander, 2003). Finally, FFT is a multilevel intervention in which the therapist works first to develop the family's inner strengths and sense of being able to improve their situation. This provides a foundation for change and future functioning that extends beyond the direct support of the therapist and other social systems. As FFT is a strength-based model, its philosophy is that the intervention offers self-sufficiency through a platform for change for the family (Sexton & Alexander, 2000; Sexton & Turner 2011). FFT therapists have diverse professional backgrounds. In one FFT intervention targeting youth with behavioral problems that was carried out in a community practice setting, the majority of therapists were Master's degree clinicians; others were Bachelor's level, and the therapists' clinical experience ranged from 1 to 40 years. Regardless of the variations in training and experience, all therapists received ongoing group-based FFT training, and outcome studies suggested that rather than the professional background, the decisive therapist characteristic was the level of treatment model adherence. Thus, the FFT intervention was found to be effective only when the therapists adhered to the treatment model (Sexton & Turner, 2011). In a previous study, undergraduate paraprofessionals trained in FFT produced significant reductions in recidivism rates among youth offenders (Barton, Alexander, Waldron, Turner, and Warburton, 1985), giving some indication of the level of training that might be required to successfully reproduce FFT (cf. Sexton 2011). In general, the FFT model emphasizes the importance of ongoing training and supervision to maintain therapists' model fidelity, and FFT provides training and supervision protocols to facilitate adherence in real-world settings (Alexander et al., 2013). As a clinical model, FFT is both flexible and structured: flexible because it requires individualized treatment strategies to be formulated by sensitive clinicians, and structured because it offers a fixed sequence of treatment strategies (Alexander & Sexton, 2002). The FFT treatment contains five interdependent and sequentially linked phases, in addition to pre-treatment and post-treatment activities. Each of the five phases has specific assessment and intervention components that are tailored to the unique characteristics of each family: (1) Engagement in change; (2) Motivation to change; (3) Relational/interpersonal assessment and change planning; (4) Behavioral Change; (5) Generalization across behavioral domains and multiple systems (Alexander & Robbins, 2010; Alexander et al, 2013). Research on FFT outcomes has emphasized investigations of the intervention's effectiveness in relation to desired outcomes (Alexander et al., 2013 p. 37–62) rather than investigating possible adverse effects (Dishion, McCord & Poulin, 1999) of FFT. Critics have suggested that future evaluations of FFT need to be carried out by a broader group of researchers to ensure rigorous evaluation of the approach in practice settings and to nuance the documentation of outcomes (Calley, 2011). Stressing desired outcomes at the expense of turning attention to the investigation of adverse effects is characteristic of much research into effects of psychotherapy, not just FFT (cf. Barlow 2010). Nonetheless, research suggests that possible adverse effects of therapy include exacerbating clients' problematic symptoms or initiating an experience of passive dependence (Dishion et al., 1999, Barlow 2010). Before the therapist contacts the family, he or she will gather all information available about the youth and his or her family (including from formal assessments and official records). The ultimate goal of the Pre-treatment phase is that the therapist is fully ready both to assist the youth and family, and also to anticipate potential barriers and utilize strengths so that a positive experience for the family may be created (Alexander & Robbins, 2010; Onedera, 2006). The engagement phase involves activities that encourage the family to attend sessions. The therapist strives to create a positive contact with the family by, for example, scheduling appointments via telephone rather than by letter (this has the additional advantage of allowing the therapist to form a first impression of the family and to identify potential problems such as resistance to or confusion about treatment). It is considered important that the therapist be culturally competent and able to assist the family in feeling respected and comfortable (Alexander et al, 2013). The goal of this phase is to create a positive and motivational context within which change can occur. Alexander (interview in Onedera, 2006) stresses that motivation is fundamental for subsequent behavioral change. It is considered important that any negativity is decreased in this early phase before targeting actual behavioral change; this is because negative emotions can prevent family members from making a realistic commitment to change (Onedera, 2006). Using a range of therapeutic techniques, the family members are helped to feel a reduction of blame, anger, and hopelessness and an increase in hopefulness (Alexander & Sexton, 2002; Sexton & Alexander, 2003). The phase consists of two major domains of activity: Changing Focus and Changing Focus attempt to negativity and family interactions by or seek to change the of how family members and each other (Alexander & Robbins, 2010; Alexander et al., 2013). The goals of relational assessment are to and information to relational and to develop for the assessment focuses on two family relationship (a) the degree of between members of the family, and (b) the in In this the therapist identifies how to approach specific changes in the family to meet the least resistance and create the most assessment provides a that not only the specific problem behavior (e.g. youth drug but also the unique and of the family members with to each The focus is to and which include interaction and of resistance (Alexander & Robbins, 2010; Alexander et al., 2013). In this the goals are to develop an implementation for change. It is important that the the unique family, each of its and their relational The therapist provides behavioral interventions to and model specific behavior changes (e.g. training, problem solving, parental skills training, and conflict It is as important that the techniques used are individualized and and that the family relational system (Alexander & Sexton, 2002; Alexander et al., 2013). In the last the goals are to maintain and support change by community The is to encourage family members to their problems using the identified strengths and skills have and to dependence on the Interventions seek to help the family to generalize across different to be more in or and to community There is a focus on the families to family has at the same the family to on their are in the is as of the of the family system (Alexander & Sexton, 2002; Alexander & Robbins, 2010; Alexander et al., 2013). FFT is a intervention on for and to 30 for more The are a of between and The therapist at least one with the youth and his or her family. The program is flexible and can be in a of settings, including at a clinical or community facility or with in the family (Sexton & Alexander, 2003). FFT has two primary to or young people's drug abuse, and to change associated with drug abuse in young people and their families. and systematic reviews have that FFT can drug abuse in can to a reduction in behavioral problems and and is associated with in family patterns and et al., 2005; Waldron, Turner & 2001; Waldron & Turner, 2008; & Liddle, 2009; Stanton & Shadish, 1997). and social have been the key theories that have FFT (Alexander et al., 2013). this theoretical indicates that problem behavior is not as a of individual both positive and negative behavior is in the social that therapists focus their attention more on Furthermore, FFT is influenced by family systems and theories the and that therapists view social and as not of problem behavior (Alexander et al., 2013). on these FFT requires that the therapists focus on the relational functions of all family relevant to the problem behavior (e.g. drug of the youth. In other FFT that individual drug abuse may be achieved through improving family and reducing dysfunctional A premise of FFT is therefore that family members of the substance-abusing youth in the treatment The about who is to in FFT in a particular is based on the of which family members will be important for the change process the youth (Alexander et al., 2013). While parental are expected to are not expected to be at the treatment to the family especially may FFT to have the youth from the and FFT treatment encompasses strategies to them in a positive change process (Alexander et al., 2013). The program outcomes may be by factors such as characteristics and program characteristics that have been found to program drug abuse reduction or history and severity of drug abuse level of peer and parental in relation to and of school and functioning (Williams et al., 2000). information is required by on the of other characteristics such as gender, ethnicity, family and conditions. characteristics are potential of treatment outcome and need to be able to the for any particular of with positive on treatment outcomes have been identified in a number of reviews of a range of treatments for youth drug abuse (Waldron & Turner, 2008; et al., 2000). is the most related to reduction in drug abuse (Williams et al., 2000; Waldron & Turner, 2008). While it is established that a therapeutic early in treatment the likelihood that young people treatment and their drug abuse (Waldron & Turner, it whether this is a direct effect or an of treatment motivation itself has been to have a positive on treatment these findings point to the importance of the FFT components of and as on treatment and The focus on family the behavioral nature of the approach, and the to engagement and motivation are all possible of intervention family behavior and functioning, and facilitate changes in young people's drug abuse. In FFT, the Engagement the first a therapist to the the family for change. This stresses the importance of the to create a positive relation to all family The therapist for the with the family by all available information about the youth and his or her family. The goal of this is to be culturally to meet the family with to and to as much as possible the The Motivation phase is linked to the Engagement phase and contains a number of intervention techniques (e.g. and and positive which can be used by the therapist to change within the family. using the intervention of the therapist cognitive and that help and thus challenge clients to identify for future change help to family members to one so that each one a for the family's as key to positive treatment outcome (Williams et al., is also linked to the support and of the family system. The family to the young person a is a possible of change related to the family systems focus of FFT. have found that FFT family and to the reduction in young people's drug abuse (Ozechowski & Liddle, 2000). are described as in the of change associated with FFT. FFT, therapeutic are associated with interventions delivered in a each family member the therapist and the therapist is to and them of their the therapist is to their emotions and Turner, Alexander & 2003). Research into the importance of therapeutic that therapists who were able to achieve a or level of in which therapists are more with than youth or were more to family in treatment et al., 2003). results the importance of the in a in the engagement and motivation drug abuse among young people is a significant social and the treatment of young people's drug abuse is and not least because the treatments for such problems are by

The abuse of alcohol is strongly associated with violent behavior in general and domestic violence in particular. The present study examined the compara-bility of dual-problem (i.e., substance abuse and conjugal violence) men in substance abuse and violence treatment milieus. Thirty males in substance abuse treatment and 33 men in violence treatment were identified as being dual-problematic and were administered the Addiction Severity Index (ASI) to assess psychosocial and substance abuse status, the Conflict Tactics Scale (CTS) for the frequency and type of abusive behavior, the Symptoms Checklist-90 (SCL-90) for psychological distress, and the 16 Personality Factor (16PF) for personality attributes. When dual-problem men from each milieu were compared on these measures, men in the substance abuse-milieu reported not only significantly more severe substance abuse problems, but also more frequent partner sexual abuse. Few other differences emerged. Thus, while current referral procedures may be appropriate in identifying and directing more severe substance abuse problems to the appropriate treatment setting, violent men with difficulties comparable to those seen in violence treatment may also be found in substance abuse treatment. These findings emphasize the need for: (1) routine objective screening for family violence and substance abuse in these two treatment milieus; (2) informed and up-to-date staff in both settings who are sufficiently prepared for the therapeutic challenges such men may present, and (3) more study of how treatment for dual-problem men may be coordinated by the violence and substance abuse treatment communities to optimize their outcome.

Increasing emphasis has been placed on the development of gender-specific treatment programs to address the unique needs of women substance abusers. Some authors have suggested that this task can be accomplished by simply providing single-gender programs; yet others have argued that simply segregating substance abuse clients by gender has no effect on outcomes. The latter have suggested that in addition to providing women-only programs, different treatment approaches must be adopted. The purpose of the study described in this article was to investigate the effect of one agency's change from mixed-gender to single-gender treatment on client retention and treatment completion. Data were collected on 305 men and 102 women who were treated in either mixedgender or single-gender settings. Results indicate that substance abuse treatment provided in single-gender settings does not significantly increase treatment retention and completion. These findings lend support to the contention that to improve treatment outcomes for women substance abusers, gender-specific treatment must do more than provide traditional treatment in a single-gender environment.

To describe a framework that can be used to determine optimal spending on substance abuse treatment in the United States. Selective review of the literature on spending for substance abuse treatment combined with an economic analysis of how to determine when spending is optimal, defining optimal spending as that which minimizes the social costs of substance use disorders. In 1997, only $11.9 billion of the $294 billion estimated social costs of substance abuse was spent on treatment. The discrepancy between the high indirect costs of illness relative to the level of spending on treatment of addictive disorders leads many to believe that the United States spends too little on treatment. In this paper, we argue that information on the social costs of substance abuse disorders and the level of spending on treatment is insufficient to determine whether current spending is optimal. We develop a framework that could be used to determine optimal spending on substance abuse treatment in the United States. We develop this framework in four steps. First, we provide background on the unique financial and delivery features of substance abuse treatment. Secondly, we outline the points raised by advocates of expanded substance abuse treatment: substance abuse has high social costs, yet few people receive the many effective treatments available partly because of financial barriers to treatment. Thirdly, we provide a framework that can be used to judge the additional benefits of alternative levels and types of spending on substance abuse treatment. Finally, we discuss the distinction between the potential impact of spending on substance abuse treatment and its actual impact, using productivity as an example of one significant portion of the costs of substance abuse. To determine optimal spending on substance abuse treatment, research should describe who receives treatment, the quality of treatment received, and how treatments relate to outcomes that comprise a large share of the economic burden of substance abuse.

Cervical cancer incidence was evaluated by histologic type, age at diagnosis, and disease stage for 6 Asian ethnic groups residing in the United States. Incidence rates were estimated for cervical squamous cell carcinoma (SCC) and adenocarcinoma by age and stage for 6 Asian ethnic groups-Asian Indian/Pakistani, Chinese, Filipino, Japanese, Korean, and Vietnamese-in 5 US cancer registry areas during 1996 through 2004. For comparison, rates among non-Hispanic whites, non-Hispanic blacks, and Hispanics were also calculated. During 1996 through 2004, Vietnamese women had the highest (18.9 per 100,000) and Asian Indian/Pakistani women had the lowest (4.5) incidence of cervical cancer; this pattern was consistent by histologic type. Vietnamese women also had the highest incidence for localized (7.3) and regional (5.7) SCC and for localized (2.4) adenocarcinoma. Contrary to the plateau of SCC incidence apparent among white women by age 45 years, SCC rates continued to rise with age among Chinese, Filipina, Korean, and Vietnamese women. There exists large variation in invasive cervical cancer incidence patterns among Asian ethnic groups in the United States and in comparison with rates for blacks, Hispanics, and whites. Early detection and prevention strategies for cervical cancer among Asians require targeted strategies by ethnic group.

ObjectivesAlthough Asian Americans are the fastest-growing racial/ethnic group in the United States, their recent mortality trends have not been sufficiently studied. This study provides a comprehensive analysis of years of life lost (YLL) from age 25 to 84 among six largest Asian ethnic groups, comparing them to non-Hispanic Whites.MethodsWe analyzed data from the CDC Multiple Cause of Death database and the American Community Survey (2000–2022) using a cause of death decomposition method.ResultsAmong college-educated individuals, all Asian ethnic groups experienced either a smaller decrease or an increase in YLL compared to Whites in 2000–2022. These disparities were not primarily driven by the COVID-19 pandemic, though Filipinos and Indians were disproportionately affected compared to Whites. Instead, the divergence in YLL trends predates 2020. Indians showed the most unfavorable trend, with YLL worsening even before the pandemic, followed by Koreans. At least 75% of the smaller YLL reductions among Asians were due to slower improvements in mortality from circulatory diseases, cancer, and diabetes. These findings indicate a less favorable mortality trend for Asian Americans compared to White Americans, particularly the college-educated, in the early 21st century. They also suggest that, over time, Asians may be deriving diminishing health returns from higher education compared to Whites.DiscussionWe discuss differential trends between Whites and Asians, as well as variation within Asian ethnic and educational groups, in the context of socioeconomic conditions, labor market dynamics, racialization in the United States, and stages of nutrition transition in countries of origin.

Introduction: The burden of breast cancer among certain Asian subpopulations is higher than previously estimated, underscoring the need for close scrutiny of Asian disparities across the breast cancer continuum from prevention through survivorship. A critical point in this process, timely and complete follow-up of screening abnormalities, is known to be inadequate among women in minority groups but has not yet been studied among disaggregated Asian populations. The objective of this investigation was to assess and compare the timeliness in follow-up after abnormal mammogram among White and Asian American women in the San Francisco Bay Area. Methods: Using data from the San Francisco Mammography Registry (SFMR), we identified women with an index abnormal screening mammogram result of BIRADS 0/3+ between the years 2000-2010. Our study sample included women who self-report White or Asian race/ ethnicity, ages 30 and older who received screening services at 10 participating SFMR-facilities. We first used chi-square statistics to compare median days to diagnostic follow-up after abnormal mammogram by patient characteristics including race/ethnicity. Cumulative percent plots were constructed to visually display the percentage of racial/ethnic groups with follow-up at multiple time intervals (i.e., 30 days, 60 days). We then conducted hierarchical regression analyses that adjust for the multilevel nature of the data, controlling for within-facility clustering of observations, estimating the associations between follow-up and sociodemographic characteristics including age and education, as well as family history of breast cancer. Subgroup comparisons identified differences in these factors which might explain abnormal mammogram follow-up disparities. Results: The total sample was 54,028 women, 70% White and 30% Asian. Among Asians, 16.2% were Chinese, 6.7% Filipina, 1.8% Japanese, 1.1% Vietnamese, 2.4% Other Asian, and 1.4% Mixed Asian. The mean age of women was 53.4 years, and the majority fell within the range of 40-74 years recommended for screening. The proportion of women who did not receive follow-up within one year after an index abnormal mammogram was 11.1% (n=6023). A higher proportion of Asian women did not receive follow-up compared to Whites (15% vs 10%). Among Asian groups, Filipinas had the highest percentage of women not receiving follow-up (18%) while Japanese women had the lowest (10.4%). In comparing those who received follow-up and those who did not, a higher proportion of women with no follow-up had lower education levels (24% vs 15%). Median time to diagnostic follow-up for White and Asian women combined was 18 days. The median follow-up time was 15 days for Whites and 26 days for Asians. The median follow-up time differed significantly among Asian ethnic groups: Japanese women had the shortest (19 days) followed by Filipinas (28 days). Vietnamese women had the longest (30 days). Hierarchical regression model results with Whites and Asians, accounting for sociodemographic variables and the effect of facility, indicate that women who did not complete high school and Asian women had higher odds of no follow-up after an abnormal mammogram at 30, 60, and 90 days compared to women with a graduate degree and Whites, respectively OR 1.3, CI: 1.16-1.41, and OR 1.2, CI: 1.14-1.27. Race was no longer significant at 60 and 90 days. For regression analyses comparing Whites and Asians by ethnicity, controlling for facility, Chinese, Filipina, Other Asian and Mixed Asian were more likely than White women to not receive follow-up, even after accounting for facilities at 30 days. At 60 days, only Filipinas were significantly more likely to receive no follow-up. At 90 days, Filipina women had slightly higher odds of no follow-up compared to Whites (OR 1.1, CI: 1.02-1.28). Conclusion: We observed disparities in timeliness to follow-up between White and Asian women and among Asian ethnic groups in the first 30-days after an abnormal screening mammogram. Disaggregation of ethnicity can identify subpopulations most in need of breast cancer control, and to provide more specific information on care delivery patterns. Citation Format: Kim Hanh Nguyen, Leah Karliner, Rena Pasick. Disparities in follow up after abnormal mammogram for multiple Asian subpopulations. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B35.

Prevalence of the metabolic syndrome using the Third Report of the National Cholesterol Educational Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) and the modified ATP III definitions for Japanese and Mongolians

Disaggregated data on Asian ethnic groups are needed to identify health disparities among Asian people. We examined COVID-19 incidence, deaths, and vaccinations among Asian ethnic groups in Santa Clara County, California. We extracted data on SARS-CoV-2 infections and COVID-19 vaccinations from December 15, 2020, through August 6, 2021, from the California Reportable Diseases Information Exchange and the California Immunization Registry. We assigned Asian ethnic group based on name for missing self-reported information. We calculated age-adjusted rates and rate ratios of infections and deaths and percentages of vaccinations by race and ethnicity and Asian ethnic group. We conducted multivariable logistic regression to examine factors associated with COVID-19 deaths. Although Asian residents had the lowest rate of SARS-CoV-2 infections per 100 000 people (1801.9; 95% CI, 1771.5-1832.7) among all racial and ethnic groups, when disaggregated by Asian ethnicity, Filipino (3169.0; 95% CI, 3049.1-3292.4) and Vietnamese (3008.4; 95% CI, 2916.9-3102.1) residents had the highest age-adjusted rates. Asian (38.7; 95% CI, 33.7-44.3) and non-Hispanic White (42.3; 95% CI, 37.5-47.5) residents had the lowest rate of COVID-19 deaths compared with all other racial and ethnic groups; however, Filipino (67.6; 95% CI, 49.1-90.8) and Vietnamese (63.7; 97% CI, 48.9-81.6) residents had significantly higher rates than the aforementioned groups did. Among all racial and ethnic groups, Asian residents had the highest completion rate of primary COVID-19 vaccine series by August 6, 2021 (87.0%; 95% CI, 86.8%-87.3%). Within Asian ethnic groups, Filipino residents had the lowest vaccination rate (65.0%; 95% CI, 64.4%-65.6%). Differences in COVID-19 incidence, deaths, and vaccinations among Asian ethnic groups highlight the importance of data collection of ethnic groups as a standard practice.

The purpose of this paper is to examine the effectiveness of mental health and substance abuse treatment in reducing crimes committed by juveniles. The observed high correlations between crime, substance abuse and poor mental health suggests that factors which reduce substance abuse and improve mental health may also be effective in reducing criminal activities. This paper uses detention data in conjunction with substance abuse and mental health treatment data for youth enrolled in the Colorado state foster care program. We analyze the impact of treatment in delaying or preventing this group of at-risk youth from engaging in criminal behavior. Results show a negative effect, i.e., longer duration before detention, for youth who receive treatment and for youth in areas with high treatment rates.

PurposeTo test hypotheses that minority ethnic people with dementia in the UK receive fewer anti-dementia drugs and more psychotropic and anticholinergic drugs associated with harms.Patients and MethodsWe analyzed UK primary care electronic health records from The Health Improvement Network (THIN) database (2014–2016), comparing psychotropic drug prescribing initiation and duration between people with dementia from White, Black, and Asian ethnic groups. We repeated analyses in people (aged 50+) without dementia, to explore whether any differences found reflected prescribing patterns in the general older population, or were specific to dementia.ResultsWe included 53,718 people with and 1,648,889 people without dementia. Among people with dementia, compared to White ethnic groups, Asian people were less likely to be prescribed anti-dementia drugs when they were potentially indicated (adjusted prevalence rate ratio 0.86 (95% Confidence Interval 0.76–0.98)), and received them for on average 15 days/year less. Compared to White groups, Asian and Black individuals with dementia were no more likely to take an antipsychotic drug, but those that had were prescribed them for 17 and 27 days/year more, respectively (190.8 (179.6–199.1) and 200.7 (191.1–206.5) days). Black people were less likely to be prescribed anxiolytics/hypnotics (0.60 (0.44–0.8)), but the duration these drugs were prescribed was similar across ethnic groups. Asian people were more likely to be prescribed anticholinergic drugs (1.43 (1.19–1.73)), in analyses unadjusted for cardiovascular comorbidities. Among people without dementia, those in the Asian and Black ethnic groups were less likely to be prescribed psychotropic drugs, relative to people from White groups.ConclusionAmong people with dementia, Asian groups received less potentially beneficial symptomatic treatments, and Asian and Black groups were prescribed antipsychotic drugs for longer than White ethnic groups. Our findings may indicate care inequalities.