Perceptions of need, service use, and barriers to service access among female methamphetamine users by Emily Sandberg Gold

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Perceptions of Need, Service Use, and Barriers to Service Access among Female Methamphetamine Users in Rural Appalachia Samuel A. MacMaster

College of Social Work, University of Tennessee, Nashville Campus , Nashville , Tennessee , USA Published online: 05 Mar 2013.

To cite this article: Samuel A. MacMaster (2013) Perceptions of Need, Service Use, and Barriers to Service Access among Female Methamphetamine Users in Rural Appalachia, Social Work in Public Health, 28:2, 109-118, DOI: 10.1080/19371918.2011.560820 To link to this article: http://dx.doi.org/10.1080/19371918.2011.560820

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Perceptions of Need, Service Use, and Barriers to Service Access among Female Methamphetamine Users in Rural Appalachia Samuel A. MacMaster College of Social Work, University of Tennessee, Nashville Campus, Nashville, Tennessee, USA

Active substance users have been characterized as ambivalent about accessing treatment services. Few studies have addressed the social context and related barriers that individuals experience in addressing substance abuse problems. These barriers appear to be heightened for female methamphetamine users living in rural areas of Appalachia. The purpose of this study is to document the willingness of active female methamphetamine users to access substance abuse treatment services, their ability to access substance abuse treatment services, and the barriers they experienced in accessing substance abuse treatment services. Findings from a sample of 153 rural female methamphetamine users revealed the majority of respondents met the criteria for substance dependence (99.3%), believed they had a drug problem (84.9%), believed they needed treatment services (62.9%), and wanted to go to treatment Snow ¸ Tˇ (51.4%). However, only one fourth (26.8%) had accessed treatment, and many had experienced barriers in attempting to enter treatment services. Keywords: Methamphetamine, drug treatment, rural, barriers

LITERATURE REVIEW Rural areas of the United States are experiencing a recent and growing increase in methamphetamine use, particularly in rural areas in the Southeast. This issue is not unique to the Southeast in general, or Tennessee in particular, as recommendations of the National Consensus Meeting on Methamphetamines and the Methamphetamine Interagency Task Force have emphasized the need for resources in rural areas to combat the rise in methamphetamine use (National Institute of Justice [NIJ], 2000; Substance Abuse and Mental Health Services Administration [SAMHSA], 2000). However, the rapid growth and acceleration of this phenomenon is unique to these specific areas. The rural, remote mountainous areas of the State of Tennessee are the epicenters of this epidemic. Until laws regarding precursors were instituted in 2005, Tennessee accounted for 75% of the methamphetamine lab seizures in the Southeast (DEA, 2004). In 1996 there were only two lab seizures in the entire state, and only 20 in 1997. Five years later in 2001, there were This project was supported by funds from the Lois and Samuel Silberman Fund Faculty Grant Program of the New York Community Trust. Address correspondence to Samuel A. MacMaster, College of Social Work, University of Tennessee, Nashville Campus, 193E Polk Avenue, Nashville, TN 37210. E-mail: smacmast@utk.edu

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461 lab seizures statewide (DEA, 2003), a number has more than doubled to 937 in Fiscal Year 2003 (South/East Tennessee Methamphetamine Task Force, 2004). Although methamphetamine labs or use are/is found in all areas of the State, the majority of labs that have been seized were located in rural areas in the eastern and central mountainous regions (South/East Tennessee Methamphetamine Task Force, 2004). The type of methamphetamine used in rural Tennessee is produced almost exclusively in clandestine labs in remote rural areas of the state. This differs significantly from the known production system in other areas of the United States, where the majority of methamphetamines are produced either on the West Coast or in Mexico by large organizations and remitted to the rest of the United States (National Institute of Drug Abuse [NIDA], 2001). According to the National Drug Intelligence Center at the Department of Justice (DOJ; 2002), manufacturers in rural areas tend to be low-income Whites, who are often users of the drug themselves. Information suggests that labs in the eastern areas of Tennessee, often run by users/producers, are the main methamphetamine providers in the area. The chemical compounds found in methamphetamines vary according to the particular recipe used by the producer. Amazingly, the chemical compounds used to manufacture the drug have traced methamphetamines consumed in rural Tennessee to two individuals. These “Johnny Appleseeds of meth” migrated from Southern California to rural Grundy County in the mid-1990s and soon after began holding methamphetamine cooking classes based on the text Secrets of Methamphetamine Manufacture (Fester, 1996). Although these two individuals have been in federal prison since 1997 where they are serving life sentences, the devastation caused by their legacy remains in rural Tennessee (Alligood, 2001). Lack of Rural-Specific Data Sources Despite the impact of rural substance use on its communities, the needs of rural areas are often overlooked by federal and state agencies. An indication of this neglect is the fact that, in comparison to urban drug trends, accurate assessment of an emerging drug trend in a rural area is virtually impossible to ascertain given the current processes of data collection at the national level. Currently there are three federal mechanisms for assessing emerging drug trends, all of which focus primarily, and in some instances exclusively, on urban and/or urban-suburban areas. NIDA’s Community Epidemiological Work Groups (CEWG) provides up-to-date descriptive and analytical information on the nature and patterns of drug abuse, emerging trends, characteristics of vulnerable populations, and social and health consequences. However, of the 21 representatives, 20 represent large metropolitan areas, and the other represents the State of Texas as a whole. National Institute of Justice’s (NIJ) Arrestee Drug Abuse Monitoring (ADAM) program also provides information regarding emerging drug abuse trends based on the self-reports and urine drug screens of arrestees; however, it concentrates exclusively on 34 metropolitan sites. The third form of national data collection, SAMHSA’s Drug Abuse Warning Network (DAWN), provides information on trends based on the mention of a drug in emergency room admissions; the data is also drawn from 21 metropolitan areas.

Prevalence of Methamphetamine Use Data suggests that methamphetamine use is prevalent nationally. According to the 2001 National Household Survey on Drug Use and Health, an estimated 9.6 million people (4.3% of the population) have tried methamphetamine at some time in their lives (SAMHSA, 2003b). There is indicator data available to document a dramatic rise in methamphetamine use and methamphetamine-related arrests in Tennessee. Admissions to substance abuse facilities for methamphetamine use have risen. According to the Treatment Episode Data Set (TEDS), admissions in which methamphetamines

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were the primary drug of choice rose from 2 in 1993 to 325 in 2001 in Tennessee (SAMHSA, 2003a). More than 98% of all amphetamine admissions were White. Among high school students in Tennessee methamphetamine use was more prevalent than other hard drugs, with 10.2% of those surveyed reporting having used methamphetamines at least once, 9.5% reporting having ever used cocaine, and 2.2% reporting having ever used heroin (Centers for Disease Control [CDC], 2000). Information from the DEA (1996, 2003, 2004, 2011) suggests that methamphetamine availability has increased significantly in the last decade throughout the South.

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Gender Disparities in Access to Substance Abuse Treatment Services Each year, only a small percentage (18.2%) of the individuals who identify a need for substance abuse treatment are able to access it, and there is a well-documented gender disparity in rates of treatment admissions (National Survey on Drug Use and Health [NSDUH], 2004). Although illicit drug use is less prevalent among women than men (6.4% vs. 10.3%) (NSDUH, 2004), analyses of the TEDS showed that women represented only about 30% of all admissions from 1992 to 1998. Gender appears to play a factor in treatment access. Men are more likely to enter substance abuse treatment (Wechsberg, Zule, Riehman, Luseno, & Lam, 2005) and to seek treatment services (Copeland, 1997). The barriers to treatment access can be conceptualized as either individually or environmentally based. Individually based barriers to treatment access are often conceptualized in terms of psychological factors and include factors such as lack of desire for treatment, treatment readiness, or treatment motivation (Joe, Simpson, & Broome, 1998; Zule, Lam, & Wechsberg, 2003). However, individual barriers may also include income, insurance status, cultural or peer norms. There are also existing environmentally based structural barriers that prevent access to treatment (Wechsberg & Zule, 2001), despite an individualâ&#x20AC;&#x2122;s willingness to enter treatment (MacMaster & Vail, 2002). Documented barriers for methamphetamine users include lack of transportation, and/or ability to self-pay for services (MacMaster, Tripp, & Argo, 2008). The purpose of this article is to document the willingness of active female methamphetamine users to access substance abuse treatment services, their ability to access substance abuse treatment services, and the barriers they experienced in accessing substance abuse treatment services.

METHOD Data Collection Data was collected by means of in-person survey in this cross-sectional study. Participants were recruited using respondent driven snowball sampling procedures, primarily through word of mouth from other respondents and recruitment flyers posted at areas known to be frequented by active methamphetamine users. To be eligible for the study an individual was required to (a) be a self-identified female, (b) self-identify as living in a rural area, (c) be poor/low income (defined as receiving less than the current poverty level per month in legal income), (d) report using methamphetamines within the last 6 months, (e) be at least age 18, (f) be interested in participating in the interview, and (g) provide verbal consent to participate. Participants were offered a $25 gift certificate at Wal-Mart as an incentive to participate. No children (younger than age 18) were interviewed as part of data collection. The first 153 individuals who met the eligibility requirements and agreed to participate make up the study sample. Informed verbal consent to participate was obtained from all participants and strict confidentiality of information was ensured. Only anonymous data was obtained in this study. Institutional Review Board approval for research with Human Subjects was applied for and obtained through the University of Tennessee.

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Instrumentation Tennessee Risk Behavior Assessment. The Tennessee Risk Behavior Assessment (TRBA) is based on the Revised Risk Behavior Assessment (RRBA) (Wechsberg, 1998) that was used with African American women who use crack cocaine and has been shown to have adequate reliability (Wechsberg et al., 2003). The TRBA was adapted from the RRBA so as to make it specific to methamphetamine use and the cultural context of rural Tennessee. The TRBA assesses demographics, alcohol and drug use, experience with and perceived need for substance abuse treatment, violence, sexual relationships and sexual risk, relationship power, sexual history and paying partners, and HIV counseling and testing. Items from the following instruments and scales are included in the RRBA and have been included in the TRBA. Global Appraisal of Individual Needs. The Global Appraisal of Individual Needs (GAIN) (Dennis, 1998) Selected items were adapted for use with rural female substance users to measure Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 2000) (diagnostic symptoms of substance use, abuse, and dependence, violence in interpersonal relationships, and criminal activities. GAIN incorporates multi-item symptom indices within each content area; most reliability tests of the indices have Cronbach’s alpha between 0.8 and 0.9 and all have alphas over 0.7. Alcohol Use Disorders Identification Test. The Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, Babor, dela Fuente, & Grant, 1993). AUDIT is a 10-item screening questionnaire developed by the World Health Organization (WHO) to identify alcohol consumption patterns that are harmful to an individual’s health. Three items address the typical amount and frequency of alcohol consumption, three items address alcohol dependency, and four items target alcohol-related problems. AUDIT was psychometrically sound with good internal consistency (Cronbach’s alpha D .869) in this study. Perceived barriers to treatment entry and completion. Items from the Pretreatment questionnaire (Neff & Zule, 2000, 2002) were adapted for use in the study including perceived barriers to treatment entry and completion. Readiness to change. Readiness to enter treatment was measured by items asking if individuals wish to enter treatment and how soon they wish to go. This measure of readiness is roughly equivalent to the determination/preparation stage of the transtheoretical stages of change model (Prochaska, DiClemente, & Norcross, 1992).

RESULTS A total of 153 female methamphetamine users who lived in rural areas of the Upper Cumberland Plateau region in eastern Tennessee completed an in-person interview.

Demographic and Social Characteristics All respondents were female with a mean age of 32.4. Most (58.9%) did not have a high school degree. Most respondents (71.9%) had lived exclusively in the communities where they currently resided, and the majority of respondents (75.1%) were born in Tennessee. Almost all (92.5%)

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reported a belief in God and nearly three fourths (71.0%) had a religious preference. All of the religious preferences reported were Protestant Christian denominations, with the most frequently preferred being Baptist (52.8%), followed by Church of Christ (13.2%), and Pentecostal (10.3%). Most respondents (84.0%) reported being single, divorced, or widowed. The vast majority (82.6%) were mothers, the number of children ranged from one to six children. Very few respondents (7.1%) reported having ever received child support from the father or the state or federal government (7.2%). Fifty eight (21.4%) of the respondentsâ&#x20AC;&#x2122; 270 reported children were in state custody. Almost one third of respondents (32.8%) reported residing in their own home, apartment, or trailer. Almost one half of respondents (44.1%) reported residing in the home of a friend of family member. More than one fifth (21.0%) reported being in some state of homelessness, or nonpermanent housing. In describing their residences, significant proportions of respondents reported that their home lacked the following: running water (4.6%), electricity (5.3%), an indoor toilet (5.9%), a bed (22.5%), a radio (23.2%), a couch (26.5%), a television (26.7%), a dresser (28.6%), a refrigerator (30.1%), a stove (31.3%), and/or a telephone (46.9%) (see Table 1). Characteristics of Early Life Respondents most frequently reported being raised by a single parent (44.7%) usually the mother (94.1% of single parents). Nearly one fourth of respondents (23.7%) reported being raised by a nonparent relative caregiver (19.1%) or within the foster care system (4.6%). Almost all respondents reported a blood relative with an alcohol (89.4%) and/or drug (76.2%) use problem. Fathers were the most frequently reported blood relative to have an alcohol (78.0%) and/or a drug (59.1%) use problem. Interestingly, mothers were more likely to be reported to have a drug use problem (43.4%) than an alcohol use problem (32.7%). Nearly one third of respondents (32.5%) reported that their primary caregiver used alcohol daily and more than one fifth of respondents (20.9%) reported that their primary caregiver used drugs daily. On average, respondents reported initiating drinking (M D 13:7, SD D 3:3), marijuana use (M D 13:9, SD D 3:0), and sexual intercourse (M D 14:0, SD D 2:5) at, or prior to, age 14. Only one half of all initial experiences with sexual intercourse were perceived to be consensual (see Table 2). Current Substance Use Although all respondents were active methamphetamine users, slightly less than one third (32.2%) reported methamphetamine as her drug choice. The most frequently reported drugs of choice were opiates (33.8%), primarily Dilaudid, Oxycontin, and Loratab. Opiates were also the most frequently used substance in the last 30 days. Despite the high level of opiate use, no one in the study reported heroin as her drug of choice. The majority of respondents (50.7%) reported that their last drug use lasted a week or longer (see Table 3). Substance Abuse Treatment Need and Perceptions of Need Mean scores on the AUDIT (M D 25:1, SD D 11:1) represent a high level of problems associated with alcohol use in the sample. Nearly all (92.5%) of respondents screened positive for an alcohol problem, and 99.3% met the DSM-IV core criteria for substance dependence ([APA], 2000), further evidence of significant alcohol use-related problems. Respondents own perceptions mirror this finding, as the overwhelming majority of respondents (84.9%) reported that they believed they have a drug problem, and nearly two thirds believed that they currently needed substance abuse treatment. The majority (51.4%) also reported that they â&#x20AC;&#x153;want to go to treatment now.â&#x20AC;?

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TABLE 1 Demographic and Current Social Characteristics of Respondents

Race-White Age Educational level Highest educational degree No degree General Equivalency Diploma High school Associate’s degree Bachelor’s degree Belief in God Have a religion Marital status Single Married Divorced/separated Widowed Housing Status Friend/family member’s home Own home or apartment Trailer Halfway House Hotel In a car Homeless Woods/camping Abandoned building On the streets/in a park Jail Sexual orientation Men Men and women Women Not currently having sex Given birth in past Number of children

53 153 134

32.4 10.7

8.2 1.6

% 100.0

58 31 60 1 1 147 145

38.4 20.5 39.7 0.7 0.7 92.5 71.0

74 24 49 3

49.3 16.0 32.7 2.0

67 33 17 8 6 6 5 4 2 2 2

44.1 21.7 11.1 5.2 3.9 3.9 3.2 2.6 1.3 1.3 1.3

106 21 4 21 149 132

69.7 13.8 2.6 13.8 82.6 2.1

1.2

Note. Percentages may total more than 100% due to rounding error.

Self-awareness of a substance abuse problem led many of the respondents to seek help independently. Nearly two thirds (60.5%) had made contact with a drug treatment program. Anecdotally, several respondents reported to the interviewers that they had called and hung up, although nearly one fourth of these respondents (23.2%) reported that they had received phone counseling at the time of their call. One half of all respondents had attended a 12-Step program meeting in the last year, and nearly one fourth had consulted with a minister or preacher regarding their substance use problem in the past year (see Table 4). Substance Abuse Treatment Access Despite the awareness of a substance abuse problem, and a desire to enter substance abuse treatment by the majority of respondents, only about one fourth (26.8%) had accessed drug treatment

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TABLE 2 Characteristics of Respondents’ Early History

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n Family of origin Single parent Two parents Other relative caregiver Foster care/social services Blood relative with alcohol problem Blood relative with drug problem Caregiver used alcohol daily Caregiver used drugs daily Age of first drank alcohol Age of first used marijuana Age of first sexual intercourse First sexual experience was consensual

68 48 29 7 141 143 151 139 147 150 149 150

44.7 31.6 19.1 4.6 89.4 76.2 32.5 20.9 13.7 13.9 14.0

3.3 3.0 2.5 50.0

TABLE 3 Respondents’ Substance Use n Drug of choice Opiates: Dilaudid, Oxycontin, Loratab Methamphetamine Marijuana Crack cocaine Benzodiazepines Cocaine-inject or snort Tobacco Combination of drugs Days used in last 30: Opiates: Dilaudid, Oxycontin, Loratab Benzodiazepines Marijuana Methamphetamine Crack cocaine Length of last drug use Part of a day All day Several days Entire week Longer than a week

1 49 25 14 3 3 3 5

33.8 32.2 16.4 9.2 2.0 2.0 2.0 3.3 12.8 10.3 9.2 7.8 4.4

32 28 14 4 72

13.6 12.5 11.7 10.1 9 21.3 18.7 9.3 2.7 48.0

services. Nearly one fifth (19.3%) of respondents desiring drug treatment had unsuccessfully attempted to access treatment services. Table 5 lists barriers to treatment access, as identified by respondents. The most frequent barriers specified appear to be related primarily to the capacity of the drug treatment services (not enough room in the program, didn’t qualify, put on a waiting list, etc.) or to financial status (not enough money, insurance wouldn’t cover, etc.).

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TABLE 4 Perceptions of Substance Use Service Need

Screened positive on the Alcohol Use Disorders Identification Test Met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria Believe “I have a drug problem” Need drug treatment now Wants to go to treatment now Called drug treatment program Attended a 12-Step meeting Consulted a minister/preacher

132

92.5

152

99.3

146 140 140 152 152 149

84.9 62.9 51.4 60.5 50.0 24.2

TABLE 5 Barriers to Service Access

Not enough money Not enough room in program Didn’t qualify Put on a waiting list Set appointment, didn’t follow through Insurance would not cover Program doesn’t take women with children Couldn’t find child care No transportation Afraid children would be taken away Family didn’t want me to go Program didn’t take women Program didn’t take meth users I take psychiatric medications

14 13 11 9 6 5 3 3 3 3 2 1 1 1

9.2 8.4 7.2 5.9 3.9 3.2 2.0 2.0 2.0 2.0 1.3 0.7 0.7 0.7

DISCUSSION This article provides a description of active female methamphetamine users residing in the rural Southeast. The present analyses are only descriptive in nature, rather than focusing on outcomes, that is, is an expressed interest to enter substance abuse treatment associated with abstinence from methamphetamine use or involvement in or completion of an abstinence-based drug treatment program. Given this limitation our findings, as such, are important. The overall aim of this study was to explore perceptions of need, substance abuse-related service use, and barriers to service access among female methamphetamine users in rural Appalachia. Prior to discussing the results, it is important to consider several limitations of the study. Although efforts were made to obtain a representative sample of active methamphetamine users, these participants are not representative of all methamphetamine users due to the sampling method. Although respondent driven sampling by active users is an improvement over convenience sampling of individuals in substance abuse treatment or a correctional facility, it is possible that these findings

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may be misleading, as a peer-driven sampling method is likely to reinforce homogeneity in the sample. Additionally, as with all cross-sectional studies, the results are only valid for the point in time in which they were collected and do not allow for causal inferences to be made. As the time and social landscape changed, individuals may have been more or less likely to involve themselves in substance abuse treatment. Despite these limitations, perhaps the most interesting findings presented here involve participants’ histories and desire to engage in drug treatment services. In terms of survey findings, data from these interviews provide a profile of the typical female methamphetamine user in rural Tennessee. Typically, the participants in this survey were younger Whites with histories of nonheroin opiate use, who appear to have histories of childhood trauma and/or minimally experienced chaotic childhoods. They were primarily single mothers who had low levels of educational attainment and nonpermanent residences without many of what are considered to be the basics of housing. They were primarily lifelong residents of the communities in which they currently resided and overwhelmingly had belief in God and religious affiliations. Given the above profile of this group it is important to recognize that the majority believed they had a drug problem (84.9%), believed they needed treatment services (62.9%), and desired to go to treatment “now” (51.4%). Of course, this data is only suggestive of a willingness to enter treatment services. The data is consistent with the notion that individual desire is not the primary barrier to drug treatment services for out-of-treatment drug users and suggests that they would engage in service use given increased access to treatment. This study does not allow formal testing of this notion, though further study is clearly warranted. There are several additional points that can be drawn from this data. First, the data on the characteristics of participants as well as their relationship to abstinence-based programming is in sharp contrast to assumptions often made about methamphetamine users, that is, they are consumed by their use to the extent that they do not care about themselves or others and thus do not make changes in high-risk behaviors, and/or they lack a willingness to consider stopping their drug use. Second, with the majority of the sample expressing a willingness to participate in abstinence-based programming, the lack of involvement in such programs may be due to a lack of availability of appropriate drug treatment services or in barriers to access to such programs. Additionally, the reliability of self-report data from drug users may be questioned, particularly with the study’s use of in-person interviews. Given the social nature of an in-person interview the expressed interest in seeking drug treatment services may simply be a measure of the perceived social desirability of this response and not the true desire of the participants. There may also be significant differences between an expressed desire to access drug treatment services and taking the actions needed to facilitate that desire. However, the NIDA instruments upon which the present measures were based have been shown to have relatively high levels of reliability. These findings have implications for the delivery and development of services for rural women who use methamphetamines. In developing services or working with this population several findings become pertinent. Women in the study reported histories that are consistent with histories with trauma, that is, substance use in the family of origin, early initiation of substance use, sexual intercourse, and reports of nonconsensual sexual intercourse. Any program must take these issues into consideration. It is also quite clear that the women involved in this study have multiple service needs in addition to substance abuse issues there is limited social support and access to resources. Despite these concerns, it is clear from these findings that participants have a willingness to be involved in treatment services. Whether this willingness translates into behavior change is outside of the scope of this study. Future research efforts may want to test such hypotheses in a more scientifically rigorous manner. However, it is also quite clear that there are significant barriers to accessing treatment services that also must be addressed that completely unrelated to the women’s perception of service needs or interest in accessing substance abuse treatment, but instead are related to the service delivery system’s capacity and/or the women’s lack of financial resources.

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