Date Published: January 3, 2019
Publisher: BioMed Central
Author(s): Emmeline Taylor, Christine Timko, Alex H. S. Harris, Mengfei Yu, Andrea K. Finlay.
Alcohol use disorder (AUD) and unhealthy drinking are prevalent among women involved in the criminal justice system and women military veterans. Pharmacotherapy—including naltrexone, topiramate, acamprosate, and disulfiram—for AUD is one form of effective treatment that is associated with better health and criminal justice outcomes. The current study examined the association of justice involvement with receipt of pharmacotherapy for AUD, as well as other patient factors that may explain variation in receipt of pharmacotherapy for AUD among women veterans who receive care at Veterans Health Administration (VHA) facilities.
Using national VHA clinical records, we examined all women VHA patients who received an AUD diagnosis during an outpatient or inpatient visit in fiscal years (FY) 2014–2017. We compared patient characteristics by justice status, defined as contact with one of the VHA’s justice outreach programs, and used a mixed-effects logistic regression model to test whether justice involvement was independently associated with odds of receiving pharmacotherapy for AUD.
Of 10,511 women veterans diagnosed with AUD in FY2017, 852 (8%) met our definition of justice-involved. Since FY2014, the percentage of women veterans who received pharmacotherapy for AUD increased (14–21%). Women justice-involved veterans and those who were homeless had higher odds of receiving pharmacotherapy for AUD (OR 1.29, CI 1.15–1.45; OR 1.35, CI 1.25–1.47). Women veterans age 55 or older or who were African-American had lower odds of receiving pharmacotherapy (OR 0.74, CI 0.67–0.82; OR 0.73, CI 0.68–0.79).
While women involved in the criminal justice system face many barriers to accessing health and social services, women justice-involved veterans had higher odds of receiving pharmacotherapy for AUD at VHA facilities compared to women veterans with no justice involvement. Legal mandates and supportive programming directed towards veterans in the criminal justice system may explain the higher rate of receipt of pharmacotherapy observed among justice-involved women veterans. Women veterans who are homeless may also have more opportunities to access and use pharmacotherapy for AUD compared to their housed counterparts.
Alcohol use can contribute to women becoming involved in the criminal justice system. Women under the influence of alcohol are at greater risk for committing a violent crime , and about a quarter of women on probation, in jail, or in state prisons, and 15% of women in federal prisons, were using alcohol when they committed their crimes . Additionally, alcohol use disorder (AUD) is more prevalent among women involved in the criminal justice system compared to women in the general population. In a nationally representative sample of jail inmates in the U.S., 37% of women self-reported alcohol abuse or dependence in the year prior to their jail admission, whereas among women in the general population, approximately 4% self-reported past year alcohol abuse or dependence [3, 4].
Using national VHA clinical records and administrative data, we conducted an observational study of all women VHA patients who received an AUD diagnosis (excluding in remission) during an outpatient or inpatient visit in fiscal years (FY) 2014–2017. AUD diagnosis was determined using International Classifications of Diseases (ICD)-9th and 10th Edition-CM codes, based on the American Society of Addiction Medicine specifications . This study was approved by the VA Palo Alto Health Care System and the Institutional Review Board at Stanford University.
The primary aims of this study were to examine the association of justice involvement with receipt of pharmacotherapy for AUD and examine other patient factors that may explain variation in receipt of pharmacotherapy for AUD among women veterans who receive care at VHA facilities. We found that women veterans who had contact with a VHA justice outreach program had higher odds of receiving pharmacotherapy for AUD compared to women veterans with no known justice involvement, even after adjusting for other patient characteristics. Programming and legal mandates for veterans with criminal justice system contact may partially explain the higher rate of pharmacotherapy receipt. Some veterans with criminal justice involvement participate in treatment courts and others are on probation or parole. Through those systems, they may have a requirement to seek AUD treatment which could include pharmacotherapy. Although we could not identify which veterans in our sample had a legal mandate for treatment, prior work with the general population exiting prison found that legal supervision and court mandates were associated with participation and adherence in SUD treatment, including pharmacotherapy [28, 29].
This study found that receipt of pharmacotherapy for AUD is increasing among women veterans generally, and among women veterans who have had contact with the VHA’s justice outreach programs specifically. Many barriers to AUD care experienced by justice-involved women are being addressed by the VHA’s integrated health care system, which helps to explain the higher odds of receiving pharmacotherapy for AUD among the women justice-involved veterans compared to their non-justice-involved counterparts. Women veterans experiencing homelessness were also more likely to receive pharmacotherapy for AUD; this finding may also be partially explained by the VHA’s integrated care model and support provided to homeless veterans. Generally, African-American and older women veterans had lower odds of receiving pharmacotherapy for AUD, suggesting that these women may have unique barriers to accessing or utilizing this effective treatment.