Transcript Lena Lundgren, PhD - SWSD2012 Database

Association Between Immigrant Status and History of
Compulsory Drug Treatment in a National Sample of
Individuals Assessed for Drug Use Disorders Through
the Swedish Public Welfare System
Lena Lundgren, Jan Brännström, Bengt-Åke Armelius, Deborah
Chassler, Stefan Moren and Sarah Trocchio
Published in: Substance Use & Misuse, 47:67–77, 2012
Presentation Prepared by Sarah Trocchio, MSW & Ivy Krull, MSW, MPH
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Background: Increasing Ethnic and Cultural Diversity in
Sweden
In 2009, 14% of the Swedish population, or
approximately 1,300,000 people were foreign
born (Statistics Sweden, 2010)
Compared to other Nordic countries, Sweden has
a higher number of immigrants and refugees
residing in the country (Statistics Sweden, 2010)
• Sweden is the third largest country in all of the European Union that accepts
political refugees
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Background: Compulsory Drug Treatment in Sweden
 The compulsory treatment law (LVM) is civil in nature and does not
include a punitive component .
 Steps to enter compulsory treatment:
1. Individual brought into Immediate custody (danger to
themselves or others due to substance abuse)
2. Assessment of need by social welfare agency-social worker
3. Mandated to enter treatment if agency determines need
 Nearly 80 % of individuals brought into custody were mandated to go
into treatment in 2008 (Gerdner & Berglund, 2011)
 Average length of treatment = 141 days (Gerdner & Berglund, 2011)
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Background: studies on Compulsory Treatment Users
Compared to Voluntary Treatment Users
When compared to individuals in Sweden who enter into drug
use disorder treatment voluntarily, compulsory drug treatment
consumers have been found to be: (Storbjork, 2010)
• Younger
• Use higher levels of drugs and alcohol
• Have less social capital and be in lower socio-economic brackets
A 2004 article (Gerdner) reviewing nine previous studies on
compulsory treatment effectiveness found:
• Between 15% and 30% of compulsory treatment users showed reductions in their
alcohol and illicit drug use post-treatment
• The % of individuals with compulsory treatment histories who are abstinent from alcohol
and drugs had increased since the 1990s
• No differences in outcomes between persons receiving compulsory treatment when
compared to voluntary treatment
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Background: Drug Use and Treatment Disparities
Research in the U.S.
 U.S. Research Findings:
 Immigrants and refugees utilize drug use disorder services less than
native-born populations (McLean-Leow, Goldstein,& McGlinchy, 2006).
 Racial and ethnic minorities experience more difficulties in obtaining
the most appropriate treatment services, are more vulnerable to gaps
in service, and may encounter bias in treatment assignments (National
Institute on Drug Abuse, 2003).
 Use of compulsory treatment can be understood as ineffective use
(or non-use) of voluntary treatment
 Using a health disparities lens:
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Research Question:
For a Swedish national sample, is there an
association between immigrant status and (self
reported) history of compulsory drug use treatment?
 Exploratory, cross-sectional study
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Methods: database
 In Sweden, nearly half of all counties use the ASI
(McLellan et al., 1992) to collect baseline data on
individuals with drug use disorders
 This data is entered into a national database, which includes data
spanning from 2002- present
 In 2009, Armelius et al (2009) used the Swedish ASI data to
create a nationally representative, individual level
database for research purposes
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Methods:
Sample Description
 Study sample was 13,309 adults in the Swedish
welfare system who had been assessed for a drug use
disorder (Lundgren et al., 2012)
 69.1 % were males, 69.0 % were native born Swedes,
and the mean age was 40.1 years (Lundgren et al, 2012 )
 A substantial number of the sample had a history of
mental health treatment
 Nearly half (44 %) had a history of outpatient psychiatric treatment
 Almost a quarter (23 %) had been in inpatient psychiatric treatment
 15 % reported a history of compulsory treatment for
narcotics
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Methods: Independent Variables
 Demographic Characteristics (age, gender,
education)
 Psychiatric Treatment History
 Criminal Justice Status
 Housing Status
 Immigrant status (one five category variable):
o Individual and their parents born in Sweden
o Individual born in either Norway, Denmark, or Finland
o Individual born outside of Sweden, Norway, Denmark, and
Finland
o Individual born in Sweden and at least one parent born in
Norway, Denmark, or Finland
o Individual born in Sweden and at least one parent born outside
Sweden, Norway, Denmark, and Finland
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Methods: Dependent Variable
A
Dichotomous
Variable:
• (1)- Self-reported history of
any compulsory treatment
for narcotics dependence
• (0)-No self-reported history
of compulsory treatment
for narcotics dependence.
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Data analysis
 Bivariate statistical analyses
 Binomial logistic regression methods where all
variables significant at the bi-variate level were
entered as a single block.
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Results: Bivariate Analyses
Table 1: Descriptive and Bivariate statistics
Independent variables
Age*** (Mean = 40.1, SD =12.8))
Gender**
Male (69.1%)
Female (30.9%)
Number of years of education*** (Mean = 10.9, SD = 2.9))
Ever received medications for psychological or emotional problems***
Yes (13.2%)
No (86.8%)
Ever been in inpatient treatment for psychiatric problems***
Yes (23.4%)
No (76.6%)
Ever been in outpatient treatment for psychiatric problems*
Yes (43.9%)
No (56.1%)
Currently on parole or probation***
Yes (12.8%)
No (87.2%)
Number of drug related crimes*** (Mean = 1.6, SD = 5.3))
Homeless status***
Yes (8.2%)
No (91.8%)
Immigration status*** (one five category variable)
Individual and their parents born in Sweden (69.0%)
Individual born in either Norway, Denmark, or Finland (6.0)
Individual born outside of Sweden, Norway, Denmark and Finland (10.0%)
Individual born in Sweden and at least one parent born in Norway, Denmark or Finland (no other
country outside Sweden) (8.0%)
Individual born in Sweden and at least one parent born outside Sweden, Norway, Denmark and
Finland (7.0%)
*p<.05 **p<.01 ***p<.001
History of compulsory drug
treatment
% or Mean (SD)
Never had compulsory drug
treatment
% or Mean (SD)
35.1 (10.3)
41.0 (13.0)
16.0
14.0
84.0
86.0
10.0 (2.1)
11.1 (2.9)
7.2
16.6
92.8
83.4
19.2
14.2
80.8
85.8
14.6
16.0
85.4
84.0
31.5
13.0
5.0 (9.1)
68.5
87.0
1.0 (3.9)
29.9
14.1
70.1
85.9
14.4
9.8
17.1
85.6
90.2
82.9
17.8
23.6
82.2
76.4
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Results: Multivariate Analyses
Table 2: Logistic Regression model: Immigration status associated with self-reported history of compulsory drug treatment (n = 13,622) controlling for age,
gender, education, history of mental treatment, criminal justice history, and homelessness
Compulsory Drug Treatment
Odds Ratio
Age***
Gender
Male
Female1
Number of years of education***
Ever received medications for psychological or emotional problems***
Ever been in inpatient treatment for psychiatric problems***
Ever been in outpatient treatment for psychiatric problems
Currently on parole or probation***
Number of drug crimes***
Homeless status***
Yes1
No
Immigrant status (one five category variable)
Individual and their parents born in Sweden
Individual born in either Norway, Denmark, or Finland 1*
Individual born outside of Sweden, Norway, Denmark and Finland 1
(95%CI: lower, upper)
.97
.97, .98
1.12
.99, 1.25
.88
.36
1.56
.99
1.70
.87, .90
.29, .44
1.38, 1.75
.89, 1.11
1.50, 1.94
1.12
1.11, 1.13
1.88
1.62, 2.20
.72
.93
1.04
.56, .93
.78, 1.10
.86, 1.24
1.41
1.19, 1.68
Individual born in Sweden and at least one parent born in Norway, Denmark or Finland 1
Individual born in Sweden and at least one parent born outside Sweden, Norway, Denmark and Finland 1***
Model Chi Square X2 = 1647.73, df =13, p <.000
Nagelkerke R Square = .198
1 Reference group
*p<.05 **p<.01 ***p<.001
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Multivariate Results: Significant results
 Respondents with higher levels of education were 12 % less
likely to report a CT history
 Those with a history of inpatient psychiatric mental health
treatment were 57 % more likely to report a CT history
 Individuals with a history of criminal drug charges were 12 %
more likely to report a CT history
 Respondents on parole or probation were 70 % more likely to
report a CT history
 Those that were homeless were 88 % more likely to report
a CT history
 Individuals who had ever received medication for psychiatric
problems were 64 % less likely to report a CT history
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Multivariate Results: Immigrant Status and
Compulsory Treatment
 No significant association between first generation
immigrant status and likelihood of reporting a history of
compulsory drug treatment for narcotics
 Non- Nordic second generation immigrants were 41 %
more likely than Swedes with Swedish parents to
report having a history of compulsory treatment for
drug use after controlling for age, gender, education,
history of inpatient and outpatient mental health
treatment, history of receiving medications for
psychiatric problems, number of times charged with a
drug related crime, homeless status, and being on
parole
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Discussion:
 Since treatment is provided free of charge, lack of
ability to pay does not explain disparate rates of
compulsory drug treatment use
 Acculturation and Assimilation studies may provide one
explanatory lens for these discrepancies;
 Acculturation research has found that substance abuse
increases as acculturation increases (Gil, Wagner & Vega, 2000;
Hahm,Lahiff, & Gutterman,2003, 2004; Ortega,Rosenheck, Alegria, & Desai, 2000)
 Also, some studies suggest that some second generation
immigrant groups are more likely to assimilate into
structurally disadvantaged groups. (Portes and Zhou, 1993; Portes and
Rambaut, 2005)
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Additional theories;
Stigma:
 Cultural stigma may prevent certain ethnic/cultural groups from
seeking help for their drug use disorders voluntarily (Bhattacharya,
2002; Abe-Kim et al., 2006; Le Myer, Zane, Cho & Takeuchi, 2009)
Unintentional Discrimination:
 Vyn Ryn and Fu (2003) found that providers’ stereotypes about help
seekers influence practice decisions
 Providers’ view of help seekers therefore can lead to discrimination and
perpetuate health disparities (Vyn Ryn & Fu, 2003)
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Policy and Practice Implications
 Culturally competent and specific outreach and drug
disorder treatment should be promoted through
Sweden
 Practitioners who complete ASI assessments for drug
use disorders should be trained in conducting
assessments with culturally diverse populations
 More research is needed exploring the role of
acculturation, stigma and discrimination on patterns of
addiction treatment use.
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Limitations
The study only includes self-reported data.
Exploratory study, it can only identify possible associations rather than causal
connections.
The measure for “recent employment status” included nine categories of a
range of activities over a three-year span of time, which inhibited the creation of
a reliable variable of employment status.
There were no specific questions asked about individuals' level of acculturation.
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References
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Armelius, B-Å. & Armelius, K. (2011). En naturalistisk studie av 14000 svenska missbruksklienter
baserad på Addiction Severity Index, ASI. In Missbruket, Kunskapen, Vården. Missbruksutredningens
forskningsbilaga. SOU 2011:6, Chapter 6,
Armelius, B-Å., Nyström, S., Engström C. & Brännström, J. (2009) Referensmaterial för bättre
använding av ASI intervjun. The Institute for the development of methodology in social work.
Socialstyrelsen (National Board of Health and Welfare). Stockholm Sweden.
Gerdner, A (2004). LVM-vårdens genomförande, utfall och effekt - En kontrollerad registerstudie i
Jämtland. I: Forskningsrapporter, Bilagedel till LVM-utredningens betänkande "Tvång och förändring",
SOU 2004:3, Socialdepartementet, s. 415-476.
Gerdner, A. & Berglund, M. (2011). Tvångsvård vid missbruk – effekt och kvalitet. In: Missbruket,
kunskapen, vården. Missbruksutredningens forskningsbilaga SOU 2011:6, s. 653-770.
Gil, A. G., Wagner, E. F. & Vega, W. A. (2000). Acculturation, familism and alcohol use among Latino
adolescent males: Longitudinal relations. Journal of Community Psychology ,28(4), 443-458.
Hahm, H. C., Lahiff, M., & Guterman, N. (2004). Asian American adolescents’ acculturation, binge
drinking, and alcohol and tobacco using peers. Journal of Community Psychology, 32(3), 295-308.
Hahm, H. C, Lahiff, M., & Guterman, N. B. (2003). Acculturation and parental attachment in Asian
American adolescents’ alcohol use. Journal of Adolescent Health, 33, 119-129.
McLellan, A.T., Kushner H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M.
(1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9,
199-213.
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References: Continued
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McLean Leow, D., Goldstein, M. & McGlinchy, L. (2006). A selective literature review:
Immigration, acculturation & substance abuse. Newton, MA: Education Development Center, Inc.
National Institute on Drug Abuse (NIDA) (2003). Drug use among racial/ethnic minorities. Rockville:
Maryland.
Ortega, A. N., Rosenheck, R., Alegria, M., & Desai, R. A. (2000). Acculturation and the lifetime risk of
psychiatric and substance use disorders among Hispanics. Journal of Nervous and Mental Disease,
188, 728–735.
Portes, A., & Zhou, M. (1993). The new second generation: Segmented assimilation and its variants.
Annals of the American Academy of Political and Social Science, 530, 74-96.
Portes, A., & Rambaut, R.G. (2005). Introduction: The second generation and children of immigrants
longitudinal study. Ethnic and Racial Studies, 28 (6), 983-989.
Statistics Sweden, (2010) Born in Sweden – but still different? The significance of parents’
country
of birth. Statistiska Centralbyrån, Stockholm, Sweden.
Storbjörk, J. (2010). Vem tvångsvårdas? Utmärkande drag för tvångsvårdade respektive frivilligt
vårdade personer med alkohol- och narkotikaproblem. Nordic Studies on Alcohol and Drugs, 27(1),
19-46.
U.S. Department of Health and Human Services. (2004). National Institute on Drug Abuse: Drug use
among racial/ethnic minorities. Retrieved from http://archives.drugabuse.gov/pdf/minorities03.pdf
Van Ryn, M. & Fu, S.S. (2003). Paved with good intentions: Do public health and human service
providers contribute to racial/ethnic disparities in health? American Journal of Public Health, 93(2),
248-255.
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QUESTIONS? COMMENTS?
Dr. Lena Lundgren
Boston University School of Social Work
[email protected]
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