International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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D. Kao et al. / International Journal of Drug Policy 25 (2014) 598–607 605 (OR = 1.32, p < 0.05) and distance to the closest Spanish-serving facility (OR = 0.74, p < 0.05). Marginal significance was found with the interaction between current users and the number of facilities (OR = 1.09, p < 0.10). Discussion The primary goal of this study was to explore the potential role of spatial accessibility of drug treatment facilities in the drug use and treatment utilization behaviors of former and current Mexi- can American heroin injectors. Due to the limited research thus far, we conceptualized this as an exploratory study, one that we hope will contribute to our understanding of the geography of drug treatment facilities and drug use desire among Hispanics with his- tory of injecting illicit drugs. Data from the CHIVA study provided a unique opportunity to look at an understudied population in a large metropolitan city in the United States. The results suggest that the spatial accessibility of treatment facilities may be related to one's concerns of injecting in the future. However, the direction of this impact is not entirely clear. On the one hand, we found that increased spatial accessibility was associated with decreased worries about injecting in the future, par- ticularly among current users. On the other hand, the results also suggest that individuals reporting a very high chance of injecting in the future tended to live closer to a facility, as well as in areas with a greater number of facilities. The latter finding seems con- sistent with previous literature that showed that drug use tended to increase the closer one lived near a clinic or treatment pro- gram (Archibald, 2008; Latkin, Glass, & Duncan, 1998). Although the directionality of this relationship is not clear, it is likely that clinics providing drug treatment services open where the need is, i.e. in communities with high rates of drug use. It is also possible that participants in the study do not perceive the existing clinics and the services they offer as being culturally relevant. However, the former finding suggests that the proximity of drug treatment programs may play an important role in fostering a change in one's perception and potentially, one's behaviors. We also found that the spatial accessibility of treatment facilities was associated with the increased likelihood of purchasing heroin inside the neighborhood, compared to outside the neighborhood. This was the case for the sample as a whole, but particularly for current users. These findings seem to highlight the challenges fac- ing drug treatment programs—which strive to be located near the target populations they serve, but as a consequence, are situated in neighborhoods whose socio demographic factors may promote or sustain drug use behaviors. Jacobson (2006) found that treat- ment facilities were more likely to be located in areas with higher levels of "disadvantage," including drug activity. Therefore, indi- viduals living near treatment facilities may simply be exposed to the neighborhood's stressors and environmental cues. Our study did not find any significant relationships between the spatial accessibility of facilities and treatment utilization, as one might expect. Neither living closer to a facility nor in an area with more facilities impacted the likelihood of ever having sought or received treatment among our participants. Previous research has shown that the average distance traveled by patients to Opioid treatment programs was 15 miles, sometimes requiring travel across state borders (Rosenblum et al., 2011). It is possible that many of our participants did not seek services at a nearby facility. One potential explanation may involve the stigma associated with having a drug addiction or seeking drug treatment. The literature suggests that individuals with a drug use problem may be hesitant to use local or neighborhood services due to the stigma associated with drug use or fear of seeing someone s/he knows (Ahern, Stuber, & Galea, 2007). The potential effects of stigma on treatment utilization and preferences may be even more dramatic for Hispanic and other minority populations, which tend to be geographically concentrated in ethnic neighborhoods and abide by traditional social roles (Portes & Rumbaut, 1996; Wen, Lauderdale, & Kandula, 2009). In the CHIVA study, our qualitative data sug- gested that participants who were in methadone maintenance (MM) treatment purposely found MM centers outside of their neighborhoods due to drug treatment and cultural stigmas. Drug treatment stigma focuses on the tenants of traditional addictions mindset that you cannot use one drug (methadone) to stop using another (heroin). In addition, the cultural value of Machismo or traditional masculinity holds that MM is a "weak method" to quit drug use, versus the more "macho method" of quitting "cold turkey" (without any treatment). These influences converge and create dissonance in users, which may explain decisions related to the distance and locations to seek treatment. Another potential explanation may be the impact of other envi- ronmental factors, such as crime. For example, Mennis, Stahler, and Barron (2012) showed that patients living in a high crime neigh- borhood were less likely to continue their treatment. Jacobson (2004) also identified other potential environmental factors that might impact treatment utilization, such as drug availability, neigh- borhood disadvantage (e.g. poverty), and the availability of other community resources. The CHIVA participants are enmeshed in the drug scene and surrounded by contextual drug cues and influences; these contextual cues have been implicated as precursors to relapse and maintenance of drug use. This study had several key limitations. The analysis was based on cross-sectional data, so the reader should be cautious in mak- ing any causal inferences. Because we were using secondary data, we were bounded by the questions and measures in the ini- tial study. Most notably, it is important to note that the original study was not designed with the intent to look at spatially- oriented research questions. Because the original study utilized specific recruitment strategies to reach a "hidden" population, over half of our participants lived in two neighborhoods in the Houston area. As a consequence, there may not have been suffi- cient spatial variation where the participants lived in relationship to where drug treatment facilities were located. Another poten- tial limitation was our focus on outpatient treatment facilities. While these facilities offer services to more than 75% of all clients requesting treatment (Substance Abuse and Mental Health Services Administration, 2009b), it would be important to deter- mine the location of various types of treatment facilities, such as methadone, self-help, hospital and residential programs in future research. Despite these limitations, this study highlights the critical need for further research on the geography of drug treatment facilities. Most notably, the drug use research literature, as it relates to the topic of spatial accessibility, has largely relied on administrative geographic units, such as states, counties, and zip codes (e.g. Archibald, 2008; Beardsley et al., 2003; Fortney et al., 1995; Jacobson, 2006; Perron et al., 2010; Whetten et al., 2006). More recently used geographies include census tracts, which are U.S. Census Bureau-designated geographies that average around 4000 persons and provide greater geographic specificity (e.g. Guerrero et al., 2011, 2013). Drug use research has certainly benefitted from the use of administrative geographic measures to identify hotspots and inform health care policy interventions and significant insights have been gathered using the use of these geographic units. How- ever, while such units (e.g. census tracts) are standardized systems for understanding geography and offer a comparative framework and common language, these measures are not resident-centered or necessarily descriptive of their subjective reality (Matthews, 2008, 2011; Stahler et al., 2008). Moreover, since administrative boundaries are arbitrarily drawn and also permeable, individuals

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