Implementing the Grand Challenge of Reducing and Preventing Alcohol Misuse and its Consequences

Audrey Begun, Diana DiNitto, Shulamith Lala Straussner

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351331562
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

'Reducing and Preventing Alcohol Misuse and Its Consequences' is one of the American Academy of Social Work and Social Welfare's Grand Challenges for Social Work, a programme launched in 2012. This book reports on the work of many social work and allied professions scholars, describing current strategies for achieving the ambitious goals identified in this Grand Challenge.

The chapters in this book fall into two broad categories: 'general' pieces, and those which address specific workforce development issues for meeting the Grand Challenge. The contributors cover the problem of alcohol misuse from a number of perspectives, including racial/ethnic disparities in alcohol treatment services; adolescents and emerging adults; and trauma/PTSD. The book also explores both technology-based interventions for reducing alcohol misuse and its consequences, and various models for preparing the workforce by effectively engaging in screening, brief intervention, and referral to treatment (SBIRT), for those experiencing alcohol-related problems complicated by other social and behavioural health problems. The book concludes with two interviews, focused global initiatives, and fetal alcohol spectrum disorders. This book was originally published as a special issue of the Journal of Social Work Practice in the Addictions.

The Grand Challenge of Reducing Gender and Racial/Ethnic Disparities in Service Access and Needs Among Adults with Alcohol Misuse

JENNIFER I. MANUEL, PHD

This study examined the impact of the Affordable Care Act (ACA) on gender and racial and ethnic disparities in accessing and using behavioral health services among a national sample of adults who reported heavy or binge alcohol use (n = 52,496) and those with alcohol use disorder (AUD; n = 22,966). Difference-in-differences models estimated service-related disparities before (2008–2009) and after (2011–2014) health care reform. A subanalysis was conducted before (2011–2013) and after (2014) full implementation of the ACA. Asian subgroups among respondents with heavy or binge drinking were excluded from substance use disorder (SUD) treatment and unmet need outcome models due to insufficient cell size. Among heavy or binge drinkers, unmet SUD treatment need decreased among Black women and increased among Black men. Mental health (MH) treatment decreased among Asian men, whereas unmet MH treatment need decreased among Hispanic men. MH treatment increased among Hispanic women with AUD. Although there were improvements in service use and access among Black and Hispanic women and Hispanic men, there were setbacks among Black and Asian men. Implications for social workers are discussed.

Alcohol misuse is a major public health problem, affecting almost a quarter of the population aged 12 years and older in the United States (Center for Behavioral Health Statistics and Quality, [CBHSQ] 2015b). Alcohol misuse, defined as excessive drinking beyond the recommended amounts, includes a continuum of alcohol problems, ranging from binge drinking (i.e., five or more drinks on the same occasion on at least 1 day or more in the past 30 days) and heavy episodic drinking (i.e., five or more drinks on the same occasion on at least 5 days or more in the past 30 days) to alcohol use disorder (AUD). In 2014, approximately 60.9 million (23%) adults aged 12 years and older reported binge alcohol use, and 16.3 million (6.2%) reported heavy alcohol use in the past year (CBHSQ, 2015b). Of the 21.5 million (8.1%) people aged 12 years and older who had a substance use disorder (SUD) in 2014, the majority (~17 million) had an AUD (CBHSQ, 2015b). Of those with an AUD, the majority were adults aged 18 years and older (~16.3 million), of whom 65% were men and 35% were women (CBHSQ, 2015b). Although Whites (13.8%) are more likely to have a lifetime AUD than Blacks (8.4%) and Hispanics (9.5%), recurrent or persistent AUD is more prevalent among Blacks and Hispanics once AUD occurs (Chartier & Caetano, 2010; Dawson et al., 2005; Hasin, Stinson, Ogburn, & Grant, 2007). Asian Americans have an estimated lifetime AUD prevalence of 3.6%, however, significant variation exists among Asian subgroups (Chartier & Caetano, 2010).

The health, social, and economic impacts of alcohol misuse are substantial, especially among vulnerable and marginalized groups, and represent an immense challenge for health and behavioral health providers, including social workers. Globally, alcohol misuse makes up about 5.1% of the burden of disease and injury and is a leading risk factor for early death and disability (World Health Organization [WHO], 2014). In the United States, the economic burden of alcohol misuse is more than $200 billion annually, of which three-quarters is related to binge drinking (Research Society on Alcoholism, 2015; Sacks, Gonzales, Bouchery, Tomedi, & Brewer, 2015). Alcohol misuse is a leading risk factor for numerous health- and injury-related conditions, most notably liver disease, cancers, and injury due to traffic crashes and falls (O’Brien et al., 2006; WHO, 2014), as well as social and legal problems (Begun, Clapp, & The Alcohol Misuse Grand Challenge Collective, 2016). The prevalence of alcohol misuse among persons with mental health (MH) disorders is also high, ranging from 45% to 60% in national studies (Grant et al., 2004; Hasin et al., 2007; Kessler et al., 1996). Despite the prevalence and adverse consequences of alcohol misuse, the vast majority of risky drinkers and people with AUD do not receive treatment (Han et al., 2015; Harris & Edlund, 2005; Ilgen et al., 2011; McLellan & Woodworth, 2014; Mojtabai, 2005).

GENDER AND RACIAL/ETHNIC DISPARITIES IN SERVICE USE AND ACCESS

Existing research on gender disparities in SUD treatment is well established. However, little attention has been paid to understanding the intersection of gender and race and ethnicity with respect to service disparities. Women have consistently been underrepresented groups in SUD treatment programs (Chartier & Caetano, 2010; Dawson et al., 2005; Greenfield, Trucco, McHugh, Lincoln, & Gallop, 2007; Ilgen et al., 2011; Marsh, Cao, & D’Aunno, 2004; Tuchman, 2010; Zemore, Mulia, Yu, Borges, & Greenfield, 2009). Historically, women have been less likely to enter treatment than men (Greenfield et al., 2007). Differences in treatment entry could reflect gaps in income and health care coverage. Compared to men, women typically earn less, on average, leading to greater challenges in paying for and accessing services over their lifetime (Fitzgerald, Cohen, Hyams, Sullivan, & Johnson, 2014). Women are also less likely to be covered by insurance because they have frequent job transitions and work part time (Henry J. Kaiser Family Foundation, 2012). Women are more likely to be insured as a dependent on their spouse’s or partner’s health insurance policy than through their own job, which places them at risk of losing their benefits if their spouse or partner loses their job or if they become divorced or widowed (Henry J. Kaiser Family Foundation, 2012). Other research suggests that gender disparities in service use might reflect differences in medical, MH, and other psychosocial problems between women and men (Marsh et al., 2004; Tuchman, 2010). For example, Weinberger, Mazure, Morlett, and McKee (2013) found that depression, which is more prevalent among women than men (Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993; Wolk & Weissman, 1995), negatively affected women’s SUD treatment outcomes.

Studies also point to disparities in SUD treatment among racial and ethnic minority groups (Chartier & Caetano, 2011; Mulia, Tam, & Schmidt, 2014; Mulvaney-Day, DeAngelo, Chen, Cook, & Alegria, 2012; Schmidt, Ye, Greenfield, & Bond, 2007; Weisner, Matzger, Tam, & Schmidt, 2002; Wells, Klap, Koike, & Sherbourne, 2001; Witbrodt, Mulia, Zemore, & Kerr, 2014), although research findings are less consistent due to differences in sample populations and methodology. Mulvaney-Day and colleagues (2012) compared two national surveys of community samples with SUDs and found that both surveys showed a lower likelihood of perceived unmet need for SUD treatment among Black respondents and a greater likelihood among Hispanic respondents than non-Hispanic White respondents (Mulvaney-Day et al., 2012). Earlier data show a different pattern of unmet need for alcohol treatment. Specifically, Asian and Hispanic respondents who reported a need for alcohol treatment had a lower likelihood of using alcohol specialty services compared to non-Hispanic White and Black respondents (Chartier & Caetano, 2010). Other research suggests racial and ethnic variation in service use by differences in access to resources. For example, Weisner and colleagues (2002) surveyed a probability sample of adult problem and dependent drinkers and found a greater likelihood of SUD treatment among Black compared to White respondents, even after adjusting for health insurance. However, Hispanic respondents were associated with a lower likelihood of SUD treatment. Differences in service use could also depend on alcohol severity. Schmidt and colleagues (2007) found that both Black and Hispanic respondents with more severe alcohol problems were less likely to receive any treatment services compared to White respondents with similar alcohol problem severity.

HEALTH CARE POLICIES TO IMPROVE ACCESS TO CARE

The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) and 2010 Affordable Care Act (ACA) offer new provisions to reduce gender and race and ethnic disparities in accessing behavioral health services and improve the overall quality of care (Clemans-Cope, Kenney, Buettgens, Carroll, & Blavin, 2012; Gettens, Henry, & Himmelstein, 2012). For example, the ACA considers SUD and MH treatment as essential benefits that new health plans must offer, extending federal parity under the MHPAEA. Under the ACA, access to health insurance exchanges in all states and Medicaid expansion in most states serve as mechanisms for increased coverage and affordable options for low-income populations. In addition, women now have expanded coverage for preventive services and comparable insurance premium rates as men for the same plan. Health care providers are receiving new opportunities for training in cultural competence (Andrulis, 2010; Salganicoff, Ranji, Beamesderfer, & Kurani, 2014). Other initiatives, such as health homes and accountable care organizations, aim to better facilitate the delivery of integrated care to improve the efficiency, quality, and coordination of health and behavioral health services.

Under the ACA, 30 million people are expected to gain coverage (Beronio, Glied, & Frank, 2014), including more than 5 million in need of behavioral health services (Ali, Mutter, & Teich, 2015). An increase in access to behavioral health services is expected to increase the demand for and use of services and presumably reduce unmet needs for such services. However, concerns exist about whether these new policies will translate to better access, especially for vulnerable populations. For example, the ACA is expected to have an impact on SUD treatment more than any other health care legislation. It is unclear, however, whether SUD treatment programs will have the capacity to meet the increased demands that might arise due to increased coverage (Humphreys & Frank, 2014). In addition, the 2012 ruling of the U.S. Supreme Court made Medicaid expansion voluntary for state governments, which will likely affect low-income and racial and ethnic minority groups. The Congressional Budget Office (2012) estimated that, without Medicaid expansion, approximately 3 million fewer people will have health insurance. As such, low-income individuals (i.e., income at or below 133% of the federal poverty level) will struggle in purchasing health insurance coverage. This includes Hispanic immigrants who have been in the United States fewer than 5 years. In states without Medicaid expansion, individuals might be expected to pay for coverage or pay a tax penalty.

THE CURRENT STUDY

Research on health care reform remains limited with respect to ACA’s impact on gender and racial and ethnic disparities in behavioral health service use and access. To date, preliminary research on the ACA’s impact suggests significant increases in insurance coverage overall and evidence of some reduction in racial and ethnic disparities (Chen, Vargas-Bustamante, Mortensen, & Ortega, 2016; McMorrow, Long, Kenney, & Anderson, 2015; Sommers, Musco, Finegold, Gunja, Burke, & McDowell, 2014). Other research has extended this work to investigate changes in treatment utilization by race and ethnicity before and after ACA implementation and found an overall increase in MH service use, particularly among Hispanics and Asians (Creedon & Cook, 2016). However, no significant changes in substance abuse treatment were found post-ACA reform, despite significant gains in insurance coverage (Creedon & Cook, 2016). The lack of significant changes might reflect other prominent barriers, such as stigma or negative attitudes about treatment (Kaufmann, Chen, Crum, & Mojtabai, 2014; Mojtabai, Chen, Kaufmann, & Crum, 2014).

In addition, given advances in gender-specific and culturally congruent services over the past decade, there might be important subgroup differences in service use and access by gender and race and ethnicity (Amaro, Arevalo, Gonzalez, Szapocznik, & Iguchi, 2006; Polak, Haug, Drachenberg, & Svikis, 2015). To date, however, limited research has investigated the intersection of gender and race and ethnicity with service use and access. Specific to alcoh...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Citation Information
• Notes on Contributors
• Introduction: Implementing the Grand Challenge of Reducing and Preventing Alcohol Misuse and Its Consequences
• 1. The Grand Challenge of Reducing Gender and Racial/Ethnic Disparities in Service Access and Needs Among Adults with Alcohol Misuse
• 2. Impact of Race on the Implementation of Empirically Supported Treatments in Substance Abuse Treatment
• 3. Recovery Schools Rise to the Challenge: Shifting Alcohol Norms and Behaviors in Youth and Emerging Adults
• 4. Empowerment in Coalitions Targeting Underage Drinking: Differential Effects of Organizational Characteristics for Volunteers and Staff
• 5. What Lies Beneath: Trauma Events, PTSD, and Alcohol Misuse in Driving Under the Influence Program Clients
• 6. Technology-Based Interventions and Trainings to Reduce the Escalation and Impact of Alcohol Problems
• 7. Effects and Durability of an SBIRT Training Curriculum for First-Year MSW Students
• 8. SBIRT Training in Social Work Education: Evaluating Change Using Standardized Patient Simulation
• 9. Evaluation of Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) Training for Social Workers
• 10. Complementing SBIRT for Alcohol Misuse with SBIRT for Trauma: A Feasibility Study
• 11. NIAAA and the Global Challenge: An Interview with Dr. Margaret (Peggy) Murray, Director, Global Alcohol Research Program, National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism
• 12. Fetal Alcohol Spectrum Disorders: An Interview with Dr. Shauna Acquavita, Assistant Professor, University of Cincinnati
• Index