Correlates of perceiving a need for treatment among adults with substance use disorder: Results from a National Survey

Addictive Behaviors 36 (2011) 1213–1222

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Addictive Behaviors

Correlates of perceiving a need for treatment among adults with substance use disorder: Results from a National Survey Sarra L. Hedden ⁎, Joseph C. Gfroerer Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavior Health Statistics and Quality, Division of Population Studies, 1 Choke Cherry Rd., Rockville, MD 20857, USA

a r t i c l e

i n f o

Keywords: Substance use disorders Treatment Epidemiology Alcohol Illicit drugs

a b s t r a c t Although millions of adults meet criteria for substance use disorder (SUD) in the U.S., only a fraction receive treatment. This may be due to individuals with SUD not perceiving a need for treatment. In order to distinguish persons with SUD who perceive a need for treatment from those who do not, correlates for the perceived need for treatment were assessed for respondents with alcohol use disorder only, drug use disorder only and both alcohol and drug use disorder. Data were from the combined 2005–2009 datasets of the National Survey on Drug Use and Health. Logistic regression models were used to calculate odds ratio and 95% confidence intervals. Results demonstrated that among respondents who need treatment but did not receive treatment for alcohol use disorder, drug use disorder and both alcohol and drug use disorders, 3.3%, 8.3% and 12.4% perceived a need for treatment, respectively. No single socio-demographic correlate was predictive of perceiving a need across the three subpopulations suggesting that screenings for substance use disorder should be done in a setting where the general population may be accessed, e.g. primary care settings. Correlates associated with perceiving a need for treatment for all three subpopulations included psychological distress, disorder severity and substance type. Although respondents with greater disorder severity were more likely to perceive a need for treatment, a large proportion of those still do not perceive a need for treatment. Screening and brief interventions would facilitate treatment entry among those with the most severe disorders. Published by Elsevier Ltd.

1. Introduction The prevalence of alcohol or drug use disorders in adults aged 18 and older has been estimated at approximately 9.2% (Substance Abuse and Mental Health Services Administration, 2010). This represents about 21 million adults in the United States (U.S.) who met criteria for a substance use disorder (SUD) in 2009 (Substance Abuse and Mental Health Services Administration, 2010). The numbers of persons meeting criteria for SUD is concerning due to mortality (Muhuri & Gfroerer, 2011; Substance Abuse and Mental Health Services Administration, 2004; Xu, Kochanek, Murphy, & Tejada-Vera, 2010) associated with SUD as well as the association of SUD with poor societal and health outcomes (Grant et al., 2004; US Department of Justice, 2006). Although, millions of adults meet criteria for SUD in the U.S., only 11.4% of adults who needed treatment (either have an SUD and/or reported receiving treatment) reported receiving treatment for SUDs in a specialty facility (Substance Abuse and Mental Health Services Administration, 2010). This may be due, in part, to individuals with SUD not perceiving a

⁎ Corresponding author. Tel.: + 1 240 276 1259; fax: + 1 240 276 1260. E-mail addresses: [email protected] (S.L. Hedden), [email protected] (J.C. Gfroerer). 0306-4603/$ – see front matter. Published by Elsevier Ltd. doi:10.1016/j.addbeh.2011.07.026

need for treatment. It has been estimated that among persons 12 years or older with SUD who have not received specialty treatment in the past year, only 5.1% perceived a need for treatment (Substance Abuse and Mental Health Services Administration, 2010). Perceiving a need for treatment may be described as one of the steps in the well-known model that describes the stages of change for addiction, the five step transtheoretical model of intentional behavior change (DiClemente, Schlundt, & Gemmell, 2004; Prochaska & DiClemente, 1984). Using this model, persons with substance use disorder who do not perceive a need for treatment are in a precontemplation stage where concern for and a sense of vulnerability due to the substance use disorder has not become apparent. Whereas, persons who perceive a need for treatment could be in any of four stages of change which occur after precontemplation: contemplation (consideration of the risks and rewards of treatment), preparation (commitment and planning for treatment), action (taking specific steps to implement a treatment plan) and maintenance (changing addiction behavior and recovery). Given that most persons with substance use disorder are in the precontemplative stage of change, it is important to distinguish characteristics of individuals in this first stage of change in order to aid them in advancing toward further stages of change, i.e. to treatment and eventual recovery. That is, distinguishing between persons with substance use disorders who perceive a need for change versus those who do not can aid in focusing screening and intervention processes by determining who to screen for

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substance use disorders in order to transition those in the precontemplative to the contemplative and further stages of change. In order to distinguish persons with substance use disorders who perceive a need for treatment versus those who do not, several studies using data on nationally representative populations have examined the correlates of a perceived need for treatment. For example, Edlund and colleagues using data from the 2004 and 2005 National Survey on Drug use and Health (NSDUH) found that among adults with alcohol use disorder a marital status of not married, lower income, older age, non-white race/ethnicity, presence of specific alcohol dependence and abuse symptoms, less than excellent health, major depressive episode and serious psychological distress were associated with a perceived need for treatment (2009). Results of an analysis of the perceived need for treatment among adults with alcohol use disorders using data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that older age, the presence of particular alcohol dependence and abuse symptoms and having a relative with an alcohol abuse diagnosis were associated with an increased odds of perceiving a need for treatment in adults (Edlund, Booth, & Feldman, 2009). Grella et al. (2009), using data from the 2001–2002 NESARC as part of an analysis among individuals meeting criteria for substance use disorders that have not received treatment, compared individuals that perceived a need for treatment versus those that did not perceive a need for treatment. Results indicated that non-white race/ethnicity, past year mood disorder and problems due to alcohol use (impairment) were associated with perceiving a need for treatment. Using data from the National Comorbidity Study (NCS, 1990–1992), Mojtabai et al. (2002) found that among participants diagnosed with a DSM-III-R mood, anxiety or substance use disorder, 32% perceived a need for treatment for mental or substance use disorders. Results of the logistic regression analyses demonstrated that participants with SUD alone were less likely to perceive a need for treatment compared to participants with co-morbid mental disorders. Other correlates of perceiving a need for treatment included a positive attitude toward mental health seeking, poor physical health condition, marital loss, female gender, younger age, maternal psychopathology, insurance coverage and suicidal thoughts and behavior even after controlling for psychopathology. An analysis using data from the 1997–1998 Healthcare for Communities (HCC) telephone survey, found that in 9585 adults, female gender, respondents who were young and middle aged, respondents with higher education, respondents with greater emotional support and respondents with greater psychiatric morbidity were more likely to perceive a need for treatment for a mental health disorder (including SUD) (Edlund, Unutzer, & Curran, 2006). Although several studies have examined correlates of perceiving a need for treatment they have been conducted among subpopulations of persons with alcohol and illicit drug use disorders and/or mental disorders together (Edlund et al., 2006; Grella, Karno, Warda, Moore, & Niv, 2009; Mojtabai, Olfson, & Mechanic, 2002) or in subpopulations of persons with alcohol use disorders (Edlund et al., 2009; Wu, Pilowsky, Schlenger, & Hasin, 2007; Wu & Ringwalt, 2004). However, no studies have examined the perceived need for treatment separately among individuals with alcohol use disorder only, drug use disorder only or both alcohol and drug use disorder. The perceived need for treatment may differ by disorder, that is individuals with more severe disorder or who have a specific type of drug use disorder may be more likely to perceive a need for treatment. Extant research has demonstrated that among a sample of 1255 drug-using arrestees, those who seek help are more likely to have more severe substance use problems and that those that use specific drugs (i.e. ‘harder’ compared to ‘softer’ drugs) are more likely to perceive a need for treatment (Fiorentine & Anglin, 1994). Another study demonstrated that individuals who have drug use disorder have almost 4 times the odds of receiving treatment compared to individuals with alcohol use disorders (Grella et al., 2009). That is, existing literature indicates that perceiving a need for treatment may differ for alcohol and drug use disorder.

In order to assess the correlates for the perceived need for treatment which may be unique to alcohol and drug use disorders (e.g. number of abuse and dependence criteria met among respondents with alcohol use disorders, or type of drug use disorder among respondents with drug use disorders) a separate analysis of perceiving a need for treatment was conducted for three subpopulations of respondents (respondents with alcohol use disorder only, drug use disorder only and both alcohol and drug use disorder) who had not received specialty treatment in the past year. Within these subpopulations, hypothesized correlates of perceiving a need for treatment within the past year were assessed, including: demographic factors, severity of substance use disorder, type of drug disorder, psychological distress, and history of treatment receipt. 2. Materials and methods 2.1. Sample Data were from the combined 2005–2009 datasets of the National Survey on Drug Use and Health (NSDUH) (Substance Abuse and Mental Health Services Administration, 2006, 2007, 2008, 2009, 2010). The 2005–2009 datasets were chosen due to their similar sample design and methodology. The NSDUH is a series of cross-sectional surveys sponsored by the Substance Abuse and Mental Health Service Administration (SAMHSA) whose primary purpose is to measure the prevalence and correlates of substance use and substance use disorders among the general population in the United States (U.S.). The target population of this survey was non-institutionalized respondents who were 12 years or older. The sample design employed stratification with an independent multistage area probability sample for each of the 50 States and the District of Columbia. For optimal privacy and confidentiality, the survey used a combination of computer-assisted personal interviewing (CAPI) conducted by an interviewer and audio computerassisted self-interviewing (ACASI). Final samples of 68,308, 67,802, 67,870, 68,736, 68, and 700 CAI interviews were obtained with a weighted CAI response rate of approximately 76%, 74%, 74%, 74%, and 76% for 2005 through 2009, respectively. An incentive of $30 was given for participation. Sampling weights were computed to account for variations in the sampling rate, to adjust for household-level and individual-level non-response, and were adjusted to ensure consistency with the 2000-based census population estimates obtained from the U.S. Census Bureau. In order to use data from the five years of combined data, a new weight was created upon aggregating the five datasets by dividing the original weight by five. Survey design variables included stratification and clustering. Further descriptions of the methods for the 2005–2009 NSDUH are on the SAMHSA website (Substance Abuse and Mental Health Services Administration, 2011). 2.2. Subpopulations: respondents who need treatment for substance use disorders by disorder Respondents classified as needing treatment for a substance use disorder were defined as adults aged 18 to 64 who met criteria for dependence or abuse of a substance in the past year and who had not received treatment at a specialty facility in the past year. A specialty facility was defined as a hospital, rehabilitation facility or mental health clinic. This population was further classified into three subpopulations: respondents who met criteria for alcohol use disorder only (without a concurrent drug use disorder), drug use disorder only (without a concurrent alcohol use disorder) and both alcohol and drug use disorder. Substance use disorder was defined based upon the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994). Respondents who needed treatment for past year alcohol use disorder only (approximate unweighted n = 21,300), drug use disorder only (approximate unweighted n = 5200) and both alcohol and drug use disorder (approximate unweighted n = 4800)

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and did not receive specialty treatment in the past year were included in the study analyses. 2.3. Outcome The main outcome, perceiving a need for treatment, is a binary variable. A respondent was classified as perceiving a need for treatment if they reported feeling a need for treatment or reported feeling an additional need for treatment in the past year for alcohol use, illicit drug use, or ‘alcohol or illicit’ drug use.

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were two-sided and tested at an alpha level of 0.05. Descriptive statistics were used to describe the sample. Specifically, percentages and standard errors were used to describe categorical variables and means and standard errors were used to describe continuous distributions. Simple and multiple logistic regression analysis were used to calculate unadjusted and adjusted odds ratio (OR) and their 95% confidence intervals (CI) for each of the three subpopulations. 3. Results 3.1. Demographics and prevalence of perceiving a need for treatment

2.4. Correlates 2.4.1. Demographics Demographic variables collected in the NSDUH survey and used in this analysis included: gender, race/ethnicity, age, education status, income and marital status. Due to sample size and efficiency considerations, race/ethnicity data were aggregated separately for each subpopulation. In order to focus the analysis on adults who were more likely to have disorders, respondents who were 18 to 64 years of age were selected. Age, a continuous variable, was divided by 5 for regression modeling. Education status was grouped into the following categories: less than high school, high school, some undergraduate school, and undergraduate/graduate school. Annual income levels consisted of less than $20,000, $20,000–$49,999, $50,000–$74,999 and greater than $75,000. Marital status was aggregated into three categories of never married, widowed/divorced/separated, and married. 2.4.2. Mental health and social consequences Mental health characteristics included past year psychological distress as measured using a total score via the Kessler 6 (K6 scale) (Furukawa, Kessler, Slade, & Andrews, 2003; Kessler et al., 2002). Also, self-reported data was collected on whether the participant had ever been arrested or booked for breaking the law. Other correlates of interest included whether or not the participant had ever in their lifetime received treatment or counseling for alcohol or drug use. 2.4.3. Abuse and dependence criteria For each of the three subpopulations, the number of abuse and dependence symptoms met for each respondent was computed in order to determine severity by symptom count. Symptoms were then aggregated into categories due to small sample size and efficiency considerations. Specifically, the categories of abuse included respondents who did not meet criteria for abuse (respondents who had 0 symptoms), respondents who had 1 symptom, and respondents who had 2 or more symptoms of abuse. For dependence, severity categories included those who did not meet criteria for dependence (respondents who had 0, 1 or 2 symptoms), had 3 to 4 symptoms, and had more than 4 symptoms. In order to determine whether the type of drug for respondents with drug use disorder was associated with perceiving a need for treatment, variables which indicated drug use disorder by specific drug classification (analgesics, cocaine, stimulants, sedative or tranquilizers, hallucinogens and marijuana) were created for analyses of respondents who needed treatment for a drug use disorder and for respondents who needed treatment for both an alcohol and a drug use disorder. Heroin was not included in these analyses due to low estimation efficiency. Inhalants were not included in the analysis of respondents with both an alcohol and a drug use disorder due to low efficiency. 2.5. Statistical analysis All analyses were performed via SAS version 9.1 (SAS Institute Inc., 2003) and SAS-callable SUDAAN version 10 (Research Triangle Institute, 2008) using the sampling weights and complex survey design variables provided in the NSDUH database. All hypotheses tests

Among adults who need treatment for alcohol use disorder, 3.3% perceived a need for treatment; whereas, 8.3% of adults who need treatment for drug use disorder and 12.4% of adults who need treatment for alcohol and drug use disorder perceived a need for treatment. 3.1.1. Characteristics of respondents who need treatment for alcohol use disorder Table 1 demonstrates the characteristics of respondents who need treatment for alcohol use disorder. Respondents who need treatment for alcohol use disorder were more likely to be male (66.0%), be white (70.8%), have a marital status of never married (47.9%). Also, 77.2% of respondents who need treatment for alcohol use disorder had health insurance coverage, 38.7% had a history of arrest and 16.5% had a history of treatment for substance use disorder. The mean age and k6 score for this population was 34.9 (se = 0.18) and 7.7 (se = 0.07), respectively. Among adults who needed treatment for alcohol use disorder, 17.6% did not meet the criteria for abuse, 60.7% had one abuse symptom, and 21.7% had ‘2 or more’ symptoms of abuse. Furthermore, 57.4% did not meet the criteria for dependence, 33.3% had 3 to 4 symptoms of dependence, and 9.3% had ‘5 or more’ symptoms of dependence. 3.1.2. Characteristics of respondents who need treatment for drug use disorder Table 2 demonstrates the characteristics of persons who need treatment for drug use disorder. Respondents who need treatment for drug use disorder were more likely to be male (61.0%), be white (66.0%), and have a marital status of never married (60.5%). Also, 66.4% of respondents who need treatment for drug use disorders had health insurance coverage, 45.1% had a history of arrest, and 24.7% had a history of treatment for substance use disorder. The mean age and k6 score for this population was 31.3 (se = 0.34) and 9.9 (se = 0.15), respectively. Among adults who need treatment for drug use disorders, 24.8% met criteria for analgesic use disorder, 15.3% met criteria for cocaine use disorder, 3.1% met criteria for hallucinogen use disorder, 8.3% met criteria for sedative or tranquilizer use disorder, 4.5% met criteria for stimulant use disorder, and 58.0% met criteria for marijuana use disorder. Among adults who need treatment for drug use disorder, 37.1% did not meet the criteria for abuse, 39.2% had one symptom of abuse, and 23.7% had ‘2 or more’ symptoms of abuse. Furthermore, 25.0% did not meet the criteria for dependence, 50.4% had 3 to 4 symptoms of dependence, 24.6% had ‘5 or more’ symptoms of dependence. 3.1.3. Characteristics of respondents who need treatment for both alcohol and drug use disorders Table 3 demonstrates the characteristics of persons who need treatment for alcohol and drug use disorder. Respondents who need treatment for alcohol and drug use disorders were more likely to be male (69.8%), be white (66.2%), and to have a marital status of never married (73.7%). Also, 66.1% of respondents who need treatment for alcohol and drug use disorder had health insurance coverage, 51.4% had a history of arrest and 27.8% had a history of treatment for substance use disorder. The mean age and k6 score for this population was 28.6 (se = 0.34) and 10.7 (se = 0.16), respectively. Among adults who need treatment for alcohol and drug use disorders, 4.0% did not have any

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Table 1 Descriptive statistics of respondents aged 18 to 64 who need treatment for alcohola, NSDUH 2005–2009. Variable Perceived a need for alcohol treatment No Yes Ageb Gender Male Female Race/ethnicity Non-Hispanic White Non-Hispanic Black Non-Hispanic Native American Non-Hispanic Asian Hispanic Non-Hispanic Other Marital status Married Widowed/divorced/separated Never married Family income Less than $20,000 $20,000–$49,999 $50,000–$74,999 $75,000 or more Health insurance No coverage Coverage Education Less than High School High School Some College College Graduate Arrested or booked No Yes Cumulative K6 scoreb Alcohol abuse Did not meet criteria (0 criteria) Met 1 criterion Met 2 or more criteria Alcohol dependence Did not meet criteria (0, 1 or 2 criteria) Met 3 to 4 criteria Met 5 or more criteria Lifetime any SUD treatment No Yes

% or meanb

se

96.71 3.29 34.89

0.25 0.25 0.18

66.03 33.97

0.53 0.53

70.76 9.89 0.80 2.24 14.63 1.69

0.57 0.40 0.10 0.16 0.46 0.16

36.22 15.91 47.87

0.68 0.50 0.63

19.85 32.96 16.56 30.62

0.50 0.57 0.45 0.64

22.81 77.19

0.50 0.50

14.57 29.62 29.47 26.34

0.46 0.55 0.53 0.56

61.26 38.74 7.71

0.60 0.60 0.07

17.61 60.71 21.68

0.48 0.60 0.52

57.39 33.33 9.28

0.63 0.60 0.34

83.48 16.52

0.48 0.48

a Respondents were classified as needing treatment for ‘alcohol only’ if they met at least one of two criteria during the past year: (1) dependent on alcohol or (2) abuse of alcohol and they did not have a concurrent drug use disorder. Subsample excludes respondents who reported receiving treatment for alcohol at a specialty facility (i.e., alcohol rehabilitation facility [inpatient or outpatient], hospital [inpatient], or mental health center) in the past year and a small percentage (b1%) of respondents with missing data. b Mean.

symptoms of abuse, 33.7% had one symptom of abuse, and 62.4% ‘2 or more’ symptoms of abuse. Furthermore, 15.6% had 0, 1 or 2 symptoms for dependence, 37.8% had 3 to 4 symptoms of dependence, and 46.6% had ‘5 or more’ symptoms of dependence. 3.2. Perceived need for treatment 3.2.1. Perceived need for treatment among respondents who need treatment for alcohol use disorder Table 4 lists the unadjusted and adjusted odds ratio (OR) and their 95% confidence intervals (CI) for perceiving a need for treatment among respondents who need treatment for alcohol use disorder. Results of the simple logistic regression models indicated that among adults who need treatment for alcohol use disorder in the past year, for every five year increase in age, the odds of perceiving a need for

Table 2 Descriptive statistics of respondents aged 18 to 64 who need treatment for illicit drugsa, NSDUH 2005–2009. Variable Perceived a need for illegal drug treatment No Yes Ageb Gender Male Female Race/ethnicity Non-Hispanic White Non-Hispanic Black Non-Hispanic Native American Non-Hispanic Asian Hispanic Non-Hispanic Other Marital status Married Widowed/divorced/separated Never married Family income Less than $20,000 $20,000–$49,000 $50,000–$74,999 $75,000 or More Health insurance No coverage Coverage Education Less than High School High School Some College College Graduate Arrested or booked No Yes Cumulative K6 scoreb Drug abuse Did not meet criteria (0 criteria) Met 1 criterion Met 2 or more criteria Drug dependence Did not meet criteria (0, 1 or 2 criteria) Met 3 to 4 criteria Met 5 or more criteria Past year analgesic use disorder No Yes Past year cocaine use disorder No Yes Past year hallucinogen use disorder No Yes Past year sedative or tranquilizer use disorder No Yes Past year stimulant use disorder No Yes Past year marijuana use disorder No Yes Lifetime any SUD treatment No Yes

% or meanb

se

91.66 8.34 31.32

0.72 0.72 0.34

61.00 39.00

1.12 1.12

65.95 16.44 0.73 2.24 12.17 2.46

1.17 0.93 0.18 0.38 0.76 0.44

24.46 15.06 60.47

1.20 0.99 1.24

31.39 35.81 13.86 18.95

1.10 1.09 0.86 0.95

33.62 66.38

1.11 1.11

24.24 34.60 28.52 12.64

1.03 1.12 1.05 0.87

54.88 45.12 9.90

1.18 1.18 0.15

37.08 39.21 23.71

1.15 1.10 1.08

25.01 50.42 24.56

1.03 1.16 1.04

75.22 24.78

1.05 1.05

84.67 15.33

0.95 0.95

96.91 3.09

0.37 0.37

91.66 8.34

0.72 0.72

95.46 4.54

0.53 0.53

42.02 57.98

1.21 1.21

75.35 24.65

1.04 1.04

a Respondents were classified as needing treatment for illicit drugs only if they met at least one of two criteria during the past year: (1) dependent on illicit drugs or (2) abuse of illicit drugs and they did not have a concurrent alcohol use disorder. Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, nonmedical use of opioid analgesics, sedatives, stimulants and tranquilizers. Subsample excludes respondents who reported receiving treatment for illicit drugs at a specialty facility (i.e., drug rehabilitation facility [inpatient or outpatient], hospital [inpatient], or mental health center) in the past year and a small percentage (b1%) of respondents with missing data. b Mean.

S.L. Hedden, J.C. Gfroerer / Addictive Behaviors 36 (2011) 1213–1222 Table 3 Descriptive statistics of respondents aged 18 to 64 who need treatment for alcohol and illicit drugsa, NSDUH 2005–2009. Variable Perceived a need for treatment No Yes Ageb Gender Male Female Race/ethnicity Non-Hispanic White Non-Hispanic Black Non-Hispanic Native American Non-Hispanic Asian Hispanic Non-Hispanic Other Marital status Married Widowed/divorced/separated Never married Family income Less than $20,000 $20,000–$49,000 $50,000–$74,999 $75,000 or more Health insurance No coverage Coverage Education Less than High School High School Some College College Graduate Arrested or booked No Yes Cumulative K6 scoreb Alcohol or drug abuse Did not meet criteria (0 criteria) Met 1 Criterion Met 2 or more criteria Alcohol or drug dependence Did not meet criteria (0, 1 or 2 criteria) Met 3 to 4 criteria Met 5 or more criteria Past year analgesic use disorder No Yes Past year cocaine use disorder No Yes Past year hallucinogen use disorder No Yes Past year sedative or tranquilizer use disorder No Yes Past year stimulant use disorder No Yes Past year marijuana use disorder No Yes Lifetime any SUD treatment No Yes

% or meanb

se

Table 4 Odds ratio (OR), Adjusted OR (AOR) and 95% confidence intervals (CI) of perceived need for treatment in respondents aged 18 to 64 who need treatment for alcohola, NSDUH 2005–2009. Variable

87.60 12.40 28.64

0.82 0.82 0.34

69.81 30.19

1.03 1.03

66.18 14.99 1.17 1.52 14.56 1.59

1.26 0.98 0.27 0.30 0.91 0.23

16.42 9.92 73.66

1.10 0.93 1.29

30.97 33.03 13.24 22.76

1.11 1.10 0.79 1.10

33.87 66.13

1.16 1.16

23.30 33.24 29.33 14.13

1.02 1.14 1.09 0.92

48.63 51.37 10.71

1.19 1.19 0.16

3.98 33.65 62.37

0.48 1.15 1.18

15.55 37.83 46.62

0.88 1.19 1.21

77.63 22.37

0.99 0.99

72.96 27.04

1.13 1.13

94.33 5.67

0.45 0.45

92.78 7.22

0.59 0.59

94.61 5.39

0.47 0.47

39.60 60.40

1.22 1.22

72.21 27.79

1.14 1.14

Due to low efficiency, estimates of heroin and inhalants were suppressed. a Respondents were classified as needing treatment for alcohol and illicit drugs if they met criteria for alcohol abuse or dependence and illicit drug abuse or dependence. Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, nonmedical use of opioid analgesics, sedatives, stimulants and tranquilizers. Subsample excludes respondents who reported receiving treatment for alcohol or illicit drugs at a specialty facility (i.e., alcohol or drug rehabilitation facility [inpatient or outpatient], hospital [inpatient], or mental health center) in the past year and a small percentage (b 1%) of respondents with missing data. b Mean.

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Simple logistic regression OR

Ageb 1.16⁎ Gender Male 1.00 Female 0.83 Race/ethnicity Non-Hispanic White 1.00 Non-Hispanic Black 1.45 Non-Hispanic Native American 1.81 Non-Hispanic Asian 0.60 Hispanic 1.11 Non-Hispanic Other 0.45 Marital status Married 1.00 Widowed/divorced/separated 1.74⁎ Never married 0.86 Family income Less than $20,000 1.00 $20,000–$49,000 0.72 $50,000–$74,999 0.67 $75,000 or More 0.39⁎ Health insurance No coverage 1.00 Coverage 0.48⁎ Education Less than High School 1.00 High School 0.78 Some College 0.56⁎ College Graduate 0.50⁎ Arrested or booked No 1.00 Yes 2.40⁎ Cumulative K6 scorec 1.10⁎ Alcohol abuse Did not meet criteria (0 criteria) 1.00 Met 1 criterion 0.69 Met 2 or more criteria 4.51⁎ Alcohol dependence Did not meet criteria (0, 1 or 2 criteria) 1.00 Met 3 to 4 criteria 3.12⁎ Met 5 or more criteria 18.14⁎ Past year any illegal drug use No 1.00 Yes 1.09 Lifetime any SUD treatment No 1.00 Yes 3.46⁎

Multiple logistic regression

95% CI

AOR

1.09, 1.24

1.20⁎ 1.08, 1.33

95% CI

0.61,1.13

1.00 0.81

0.57, 1.16

0.91, 0.79, 0.19, 0.68, 0.20,

2.33 4.12 1.89 1.83 1.02

1.00 1.37 1.22 0.83 1.00 0.36

0.79, 0.57, 0.22, 0.61, 0.14,

1.13, 2.68 0.59, 1.25

1.00 0.95 1.04

0.57, 1.59 0.62, 1.76

0.48, 1.10 0.40, 1.10 0.24, 0.64

1.00 0.98 1.15 0.65

0.61, 1.58 0.66, 1.99 0.35, 1.21

0.34, 0.68

1.00 0.60⁎ 0.41, 0.87

0.49, 1.25 0.35, 0.89 0.30, 0.83

1.00 1.02 0.93 1.17

1.76, 3.29 1.08, 1.12

1.00 1.35 0.97, 1.89 1.06⁎ 1.04, 1.09

0.43, 1.12 2.88, 7.08

1.00 1.74 0.98, 3.11 4.03⁎ 2.45, 6.65

2.37 2.61 3.13 1.63 0.94

0.61, 1.69 0.56, 1.53 0.65, 2.10

1.00 1.91, 5.12 2.83⁎ 1.61, 5.00 11.54, 28.53 8.84⁎ 4.86, 16.08

0.81, 1.46

1.00 1.01

0.73, 1.41

2.51, 4.78

1.00 1.48

1.00, 2.20

a

Respondents were classified as needing treatment for ‘alcohol only’ if they met at least one of two criteria during the past year: (1) dependent on alcohol or (2) abuse of alcohol and they did not have a concurrent drug use disorder. Subsample excludes respondents who reported receiving treatment for alcohol at a specialty facility (i.e., alcohol rehabilitation facility [inpatient or outpatient], hospital [inpatient], or mental health center) in the past year and a small percentage (b1%) of respondents with missing data. b For the calculation of the Odds ratio, age was divided by five to reflect changes in odds for five year increments. c A design effect was added to all models that included the SPD variable, the K6 scale for 2008 and 2009 differs from that of 2005–2007. ⁎ pb0.05.

treatment increased by 16% (OR = 1.16, 95%CI = 1.09, 1.24). Among respondents who need treatment for alcohol use disorder, perceiving a need for treatment is more likely among respondents with a marital status of ‘widowed, divorced or separated’ compared to a marital status of married (OR = 1.74, 95% CI = 1.13, 2.68). Also, perceiving a need for treatment was more likely for respondents with a history of arrest (OR = 2.40, 95% CI = 1.76, 3.29). A perceived need for treatment also was associated with the number of symptoms of alcohol abuse

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and dependence. That is, respondents who had ‘2 or more’ symptoms for alcohol abuse were more like to perceive a need for treatment compared to respondents who did not meet criteria for alcohol abuse. However, the perceived need for treatment was not associated with having 1 symptom for abuse. For alcohol dependence, respondent who had ‘3 to 4’ or ‘5 or more’ symptoms were more likely to perceive a need for treatment than respondents who did not meet criteria for alcohol dependence. Perceiving a need for treatment also was more likely among respondents who reported a history of treatment for substance use (OR = 3.46, 95% CI = 2.51, 4.78). Results of the multiple logistic regression analysis indicate that for every 5 year increase in age the odds for perceiving a need for treatment increased by 20% (AOR= 1.20, 95% CI= 1.08, 1.33). Respondents with health insurance coverage were less likely to perceive a need for treatment than respondents without health insurance (AOR= 0.60, 95% CI= 0.41, 0.87). For every unit increase in psychological distress, the odds of perceiving a need for treatment increased by 6% (AOR = 1.06, 95% CI= 1.04, 1.09). Similar to the unadjusted results, respondents who had a greater number of symptoms of abuse and dependence were more likely to perceive a need for treatment compared to respondents who did not meet criteria for abuse or dependence. 3.2.2. Perceived need for treatment among respondents who need treatment for drug use disorder Results of the simple logistic regression models indicate that among persons who need treatment for drug use disorder (Table 5) older age is associated with perceiving a need for treatment (OR = 1.17, 95% CI = 1.10, 1.25). Respondents with a marital status of never married were less likely to perceive a need for treatment than respondents with a marital status of married (OR = 0.56, 95% CI = 0.36, 0.87). Family income was associated with perceiving a need for treatment with respondents with a family income of $20,000 to $49,999 and more than $75,000 less likely to perceive a need for treatment than respondents with a family income of less than $20,000. Respondents reporting a history of arrest had 2.23 (95% CI = 1.55, 3.19) the odds of perceiving a need for treatment than respondents without a history of arrest. Also, for every unit increase in psychological distress the odds of perceiving a need for treatment increased by 7%. (AOR = 1.07, 95% CI = 1.05, 1.10). Having ‘2 or more’ symptoms of drug abuse was associated with perceiving a need for treatment (OR = 7.62, 95% CI = 4.61, 12.58). Respondents who met criteria for drug dependence were more likely to perceive a need for treatment than respondents who did not meet criteria for dependence; respondents who had 3 to 4 symptoms of dependence (OR = 2.22, 95% CI = 1.02, 4.86) and respondents who had ‘5 or more’ symptoms of dependence (OR = 14.47, 95% CI = 6.69, 31.29) were more likely to perceive a need for treatment. Among respondents who needed treatment for drug use disorder in the past year, perceiving a need for treatment was more likely among respondents with a past year analgesic (OR = 1.50, 95% CI = 1.01, 1.22), cocaine (OR = 5.69, 95% CI = 3.80, 8.52), and stimulant use disorder (OR = 2.41, 95% CI = 1.33, 4.38). Whereas, perceiving a need for treatment was less likely among respondents with past year hallucinogen (OR = 0.21, 95% CI = 0.08, 0.53) or marijuana use disorder (OR = 0.30, 0.20, 0.43) and was not associated with having sedative or tranquilizer use disorder. Finally, respondents with a history of treatment for substance use disorder had 5.85 (95% CI = 4.02, 8.52) the odds of perceiving a need for treatment than respondents without a history of treatment. Results of the multiple logistic regression demonstrated that respondents with a marital status of never married were less likely to perceive a need for treatment than those with a marital status of married. Also, respondents with cocaine use disorder (AOR = 1.85, 95% CI = 1.07, 3.18) were more likely to perceive a need for treatment. Also, respondents with hallucinogen use disorder were less likely to perceive a need for treatment (AOR = 0.21, 95% CI = 0.08, 0.56).

Furthermore, perceiving a need for treatment was not associated with having an analgesic, stimulant, sedative/tranquilizer, or marijuana use disorder. Similar to the unadjusted results, for every unit increase in psychological distress the odds of perceiving a need for treatment increased by 4% (AOR = 1.04, 95% CI = 1.01, 1.07). The severity of abuse and dependence was associated with perceiving a need for treatment, with respondents who met more symptoms of drug abuse or dependence more likely to perceive a need for treatment than respondents who did not meet criteria for abuse or dependence. Having a history of treatment for substance use disorder also was associated with perceiving a need for treatment in the adjusted model (AOR = 2.98, 95% CI = 1.97, 4.52). 3.2.3. Perceived a need for treatment among respondents who need treatment for alcohol and drug use disorder Results of the simple logistic regression models indicate that among respondents who need treatment for both alcohol and drug use disorder (Table 6), for every 5 year increase in age the odds of perceiving a need for treatment increased by 17% (OR = 1.17, 95% CI= 1.08, 1.26). Among African Americans, perceiving a need for treatment was 1.80 times the odds (95% CI = 1.21, 2.67) for Whites. Perceiving a need for treatment was more likely for respondents with a history of arrest than respondent without a history of arrest (OR = 2.02, 95% CI= 1.49, 2.74). For every unit increase in psychological distress, the odds of perceiving a need for treatment increased by 7% (OR = 1.07, 95% CI = 1.05, 1.09). Perceiving a need for treatment also was more likely among respondents who had more symptoms for alcohol or drug abuse or dependence. Specifically, respondents who had ‘2 or more’ of abuse for alcohol or drugs were more likely to perceive a need for treatment than respondents who did not meet criteria for abuse. Also, respondents who had ‘5 or more’ symptoms of dependence for alcohol or drugs were more likely to perceive a need for treatment than respondents with 0, 1 or 2 symptoms of dependence. Respondents with analgesic use disorder (OR = 1.42, 95% CI = 1.04, 1.93) cocaine use disorder (OR = 2.21, 95% CI = 1.62, 3.00), sedative/tranquilizer use disorder (OR = 2.06, 95% CI = 1.34, 3.18) or stimulant use disorder (OR = 2.36, 95% CI= 1.51, 3.68) were more likely to perceive a need for treatment. Also, respondents with marijuana use disorder had 0.57 (95% CI=0.42, 0.76) the odds of perceiving a need for treatment than respondents without marijuana use disorder. Furthermore, perceiving a need for treatment was not associated with having a hallucinogen use disorder. However, perceiving a need for treatment was associated with having a history of treatment for substance use (OR=2.50, 95% CI= 1.83, 3.41). Results from the multiple logistic regression model indicate that African Americans were more likely to perceive a need for treatment compared to Whites (AOR = 2.08, 95% CI = 1.34, 3.23). Having a history of arrest (AOR = 1.48, 95% CI = 1.04, 2.11) and a history of treatment for substance use (AOR = 1.51, 95% CI = 1.06, 2.15) was associated with perceiving a need for treatment. For every unit increase in psychological distress the odds of perceiving a need for treatment increased by 4% (AOR = 1.04, 95% CI = 1.02, 1.07). Finally, perceiving a need for treatment was more likely among persons who had ‘2 or more’ symptoms of abuse for alcohol or drugs (AOR = 3.73, 95% CI = 1.26, 11.10) compared to respondents with 0 symptoms of abuse. Also, perceiving a need for treatment was associated with having ‘5 or more’ symptoms of dependence for alcohol or drugs (AOR = 4.98, 95% CI = 1.98, 12.55). Furthermore, respondents with stimulant use disorder (AOR = 1.67, 95% CI = 1.02, 2.74) were more likely to perceive a need for treatment. 4. Discussion This study assesses the prevalence and correlates of perceiving a need for treatment separately for individuals who need but did not receive treatment for alcohol use disorder only, illicit drug use disorder only and both alcohol and illicit drug use disorders in the past

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Table 5 Odds ratio (OR), Adjusted OR (AOR) and 95% confidence intervals (CI) of perceived need for treatment in respondents aged 18 to 64 who need treatment for illicit drugsa, NSDUH 2005–2009. Variable

Simple logistic regression OR

b

Age Gender Male Female Race/Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic or Non-Hispanic Other Marital status Married Widowed/divorced/separated Never married Family income Less Than $20,000 $20,000–$49,999 $50,000–$74,999 $75,000 or More Health Insurance No coverage Coverage Education Less than High School High School Some College College Graduate Arrested or booked No Yes Cumulative K6 scorec Drug abuse Did not meet criteria (0 criteria) Met 1 criterion Met 2 or more criteria Drug dependence Did not meet criteria (0, 1 or 2 criteria) Met 3 to 4 criteria Met 5 or more criteria Past year analgesic use disorder No Yes Past year cocaine use disorder No Yes Past year hallucinogen use disorder No Yes Past year stimulant use disorder No Yes Past year sedative or tranquilizer use disorder No Yes Past year marijuana use disorder No Yes Lifetime any SUD treatment No Yes

Multiple logistic regression 95% CI

AOR

95% CI

1.17⁎

1.10, 1.25

0.98

0.88, 1.09

1.00 1.20

0.83, 1.73

1.00 0.96

0.62, 1.47

1.00 1.28 0.85

0.75, 2.18 0.48, 1.49

1.00 1.22 1.09

0.64, 2.32 0.60, 1.98

1.00 1.66 0.56⁎

0.96, 2.88 0.36, 0.87

1.00 0.89 0.55⁎

0.47, 1.67 0.31, 0.95

1.00 0.62⁎ 0.70 0.45⁎

0.40, 0.95 0.36, 1.35 0.26, 0.75

1.00 0.84 0.84 0.74

0.50, 1.40 0.43, 1.65 0.39, 1.40

1.00 0.68⁎

0.47, 0.98

1.00 0.81

0.55, 1.18

1.00 0.96 0.69 0.45

0.62, 1.51 0.43, 1.12 0.20, 1.00

1.00 1.21 1.03 0.99

0.74, 2.00 0.60, 1.76 0.39, 2.51

1.00 2.23⁎ 1.07⁎

1.55, 3.19 1.05, 1.10

1.00 1.24 1.04⁎

0.80, 1.94 1.01, 1.07

1.00 1.17 7.62⁎

0.68, 2.03 4.61, 12.58

1.00 1.57 3.04⁎

0.85, 2.88 1.59, 5.82

1.00 2.22⁎ 14.47⁎

1.02, 4.86 6.69, 31.29

1.00 2.63⁎ 7.20⁎

1.22, 5.66 3.20, 16.18

1.00 1.50⁎

1.01, 2.22

1.00 0.98

0.61, 1.56

1.00 5.69⁎

3.80, 8.52

1.00 1.85⁎

1.07, 3.18

1.00 0.21⁎

0.08, 0.53

1.00 0.21⁎

0.08, 0.56

1.00 2.41⁎

1.33, 4.38

1.00 0.97

0.48, 1.99

1.00 1.70

0.88, 3.27

1.00 0.71

0.34, 1.47

1.00 0.30⁎

0.20, 0.43

1.00 0.71

0.45, 1.13

1.00 5.85⁎

4.02, 8.52

1.00 2.98⁎

1.97, 4.52

Due to low efficiency, estimates of heroin and inhalants were not included in the model. a Respondents were classified as needing treatment for an illicit drug problem if they met at least one of two criteria during the past year: (1) dependent on illicit drugs or (2) abuse of illicit drugs and they did not have a concurrent alcohol use disorder marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, nonmedical use of opioid analgesics, sedatives, stimulants and tranquilizers. Subsample excludes respondents who reported receiving treatment for illicit drugs at a specialty facility (i.e., drug rehabilitation facility [inpatient or outpatient], hospital [inpatient], or mental health center) in the past year and a small percentage (b 1%) of respondents with missing data. b For the calculation of the Odds ratio, age was divided by five to reflect changes in odds for five year increments. c A design effect was added to all models that included the SPD variable, the K6 scale for 2008 and 2009 differs. ⁎ pb0.05.

year. Similar to estimates from other studies that indicate that perceiving a need for treatment among individuals that need treatment is infrequent (Charuvastra, Anderson, Friedmann, & Stein, 2002; Edlund et al., 2006, 2009; Falck et al., 2007; Fiorentine & Anglin,

1994; Grella et al., 2009; Mojtabai et al., 2002), results from this study found that a considerable proportion of persons who need treatment for substance use disorders are not perceiving a need for treatment and are therefore not receiving treatment.

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Table 6 Odds ratio (OR), Adjusted OR (AOR) and 95% confidence intervals (CI) of perceived need for treatment of alcohol or illicit drugs in respondents aged 18 to 64 who need treatment for alcohol and illicit drugsa, NSDUH 2005–2009. Variable

b

Age Gender Male Female Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic Other Marital status Married Widowed/divorced/separated Never married Family income Less than $20,000 $20,000–$49,000 $50,000–$74,999 $75,000 or more Health insurance No coverage Coverage Education Less than High School High School Some College College Graduate Arrested or booked No Yes Cumulative K6 scorec Drug abuse Did not meet criteria (0 criteria) Met 1 criterion Met 2 or more criteria Drug dependence Did not meet criteria (0, 1 or 2 criteria) Met 3 to 4 criteria Met 5 or more criteria Past year analgesic use disorder No Yes Past year cocaine use disorder No Yes Past year hallucinogen use disorder No Yes Past year sedative or tranquilizer use disorder No Yes Past year stimulant use disorder No Yes Past year marijuana use disorder No Yes Lifetime any SUD treatment No Yes

Simple logistic regression

Multiple logistic regression

OR

95% CI

AOR

95% CI

1.17⁎

1.08, 1.26

1.05

0.95, 1.16

1.00 1.00

0.75, 1.34

1.00 0.85

0.60, 1.19

1.00 1.80⁎ 0.73 1.08

1.21, 2.67 0.32, 1.69 0.69, 1.69

1.00 2.08⁎ 0.84 1.38

1.34, 3.23 0.38, 1.88 0.83, 2.29

1.00 1.73 0.74

0.95, 3.14 0.47, 1.16

1.00 1.14 0.88

0.59, 2.20 0.57, 1.37

1.00 0.98 1.03 0.68

0.70, 1.38 0.64, 1.67 0.42, 1.10

1.00 1.07 1.42 0.98

0.74, 1.57 0.84, 2.37 0.58, 1.64

1.00 0.76

0.56, 1.03

1.00 0.99

0.73, 1.36

1.00 1.07 0.76 0.79

0.75, 1.52 0.51, 1.14 0.46, 1.35

1.00 1.05 0.95 1.38

0.70, 1.56 0.62, 1.44 0.74, 2.56

1.00 2.02⁎ 1.07⁎

1.49, 2.74 1.05, 1.09

1.00 1.48⁎ 1.04⁎

1.04, 2.11 1.02, 1.07

1.00 1.17 4.43⁎

0.38, 3.57 1.54, 12.79

1.00 1.76 3.73⁎

0.56, 5.60 1.26, 11.10

1.00 2.51 8.99⁎

1.00, 6.33 3.65, 22.13

1.00 2.02 4.98⁎

0.79, 5.20 1.98, 12.55

1.00 1.42⁎

1.04, 1.93

1.00 1.05

0.69, 1.60

1.00 2.21⁎

1.62, 3.00

1.00 1.24

0.84, 1.85

1.00 1.30

0.82, 2.06

1.00 1.19

0.72, 1.96

1.00 2.06⁎

1.34, 3.18

1.00 1.22

0.72, 2.06

1.00 2.36⁎

1.51, 3.68

1.00 1.67⁎

1.02, 2.74

1.00 0.57⁎

0.42, 0.76

1.00 0.77

0.53, 1.13

1.00 2.50⁎

1.83, 3.41

1.00 1.51⁎

1.06, 2.15

Due to low efficiency, estimates of heroin and inhalants were not included in the model. a Respondents were classified as needing treatment for alcohol and illicit drugs if they met criteria for alcohol abuse or dependence and illicit drug abuse or dependence. Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, nonmedical use of opioid analgesics, sedatives, stimulants and tranquilizers. Subsample excludes respondents who reported receiving treatment for alcohol or illicit drugs at a specialty facility (i.e., alcohol or drug rehabilitation facility [inpatient or outpatient], hospital [inpatient], or mental health center) in the past year and a small percentage (b 1%) of respondents with missing data. b For the calculation of the Odds ratio, age was divided by five to reflect changes in odds for five year. c OR for SPD controls for a design effect, the K6 scale for 2008 and 2009 differs from that of 2005–2007. ⁎ pb0.05.

Also, individuals with alcohol use disorder are less likely to perceive a need for treatment compared to individuals with drug or both drug and alcohol use disorders. This may be due to the respective legal and illegal status of alcohol and drugs (Grella et al., 2009). Unlike

illicit drug use, alcohol use is a ‘socially normative’ behavior and therefore the abuse and dependence of alcohol may be less likely to be perceived as necessary for treatment compared to drug abuse or dependence.

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Various correlates also were associated with perceiving a need for treatment. Similar to past studies, perceiving a need for treatment among respondents who needed treatment for alcohol use disorder was less likely for respondents that were younger (Edlund et al., 2006, 2009; Mojtabai et al., 2002). Compared to respondents with a marital status of married those having a marital status of never married were less likely to perceive a need for treatment among those who needed treatment for a drug use disorder. Among respondents with both an alcohol and drug use disorder, African Americans were more likely to perceive a need for treatment compared to Whites. Unlike a past study of the perceived need for treatment for alcohol use disorders using the combined 2004 and 2005 NSDUH data, adjusted results from this study did not indicate that marital status or family income was associated with perceiving a need for treatment (Edlund et al., 2009). Differences in results between this study and the study by Edlund and colleagues could be due to the different independent variables defined in the multiple logistic regression models or may be due to the differences in how the subpopulations were defined for each study. For this study, the subgroup of respondents aged 18 to 64 with alcohol dependence did not include individuals with drug use disorders. Furthermore, the definition of persons needing treatment did not include individuals who had received specialty treatment in the past year. Although various socio-demographic correlates listed above were found to be associated with perceiving a need for treatment, many of the socio-demographic variables assessed were not associated with perceiving a need for treatment. Also, no single socio-demographic correlate was predictive of perceiving a need across the three subpopulations. Although determining which individuals perceive a need for treatment versus those that do not could aid in targeting substance use screening and/or brief interventions, these results, which indicate that few social demographic characteristics differentiate individuals who perceive a need for treatment versus those that do not, suggest that screenings for substance use disorder should be done in a setting where the general population may be accessed such as through primary care practices, emergency rooms or community settings. Given that 70% of persons in the U.S. visit a general care provider every year (Druss, Mays, Edwards, & Chapman, 2010; Ezzati-Rice & Rohde, 2008), these providers are well-positioned for population-based screening for substance use disorders. That is, screenings and brief educational interventions of the general population could be used to increase knowledge and awareness of the symptoms of substance use disorders and their consequences. A federally funded screening, brief interventions, referrals to treatment (SBIRT) service program which has been initiated by SAMHSA has demonstrated efficacy for a reduction in illicit drug use and heavy alcohol use across a range of health care settings (Madras et al., 2009). This program or similar programs could be put into place in a variety of settings to increase the awareness and recognition of substance use disorders among the general population. Although various social demographic characteristics were not associated with perceiving a need for treatment, perceiving a need for treatment was more likely for respondents with greater scores of psychological distress for all three subgroups. This result is consistent with literature that demonstrates that respondents with co-occurring mental health problems were more likely to perceive a need for and seek treatment for substance use (Edlund et al., 2009; Falck et al., 2007). Also consistent with extant literature, perceiving a need for treatment was more likely for respondents with a history of substance use treatment among respondents who needed treatment for drug use disorders and both drug and alcohol use disorders (Falck et al., 2007; Grella et al., 2009). Furthermore, respondents with a history of arrest were more likely to perceive a need for treatment; this result is consistent with literature which suggests that respondents with alcohol or drug related legal problems are more likely to perceive a need for treatment (Edlund et al., 2009; Longshore, Hsieh, & Anglin, 1993).

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Disorder severity also was associated with perceiving a need for treatment for all three subpopulations. Disorder severity was associated with perceiving a need for treatment among respondents with alcohol use disorders. Specifically, respondents who had ‘2 or more’ symptoms of alcohol abuse and respondents who had ‘3 to 4’ or ‘5 or more’ symptoms of alcohol dependence were more likely to perceive a need for treatment than respondents who did not meet the criteria for alcohol abuse or dependence. That is, individuals who had more symptoms of alcohol use disorder may be more aware of their need for treatment. Although respondents who had more symptoms of alcohol abuse or dependence were more likely to perceive a need for treatment, those with more symptoms who perceived a need for treatment were still only a small percentage of those who need treatment. Among respondents with alcohol use disorder, only 9.2% of those who had ‘2 or more’ abuse symptoms perceived a need for treatment. Also, only 3.3% and 16.7% of those who had ‘3 to 4’ and ‘5 or more’ dependence symptoms perceived a need for treatment. Disorder severity among respondents with drug use disorder and with both alcohol and drug use disorders also was associated with perceiving a need for treatment. Specifically, among respondents with drug use disorders, perceiving a need for treatment was more likely for respondents who had more symptoms of dependence or abuse. Among respondents with drug dependence, 4.4% of individuals who had ‘3 to 4’ symptoms and 23.0% of respondents who had ‘5 or more’ symptoms perceived a need for treatment. Furthermore, among respondents with both alcohol and drug use disorders, only 18.9% of individuals who met criteria for both alcohol and drug dependence perceived a need for treatment. Results signify that although respondents with a greater severity of substance use disorder are more likely to perceive a need for treatment, a large proportion of those with greater severity still do not perceive a need for and therefore do not receive treatment. That is, screening and brief interventions may facilitate treatment entry among adults with the most severe disorders. Among respondents that need treatment for drug use disorder those with particular drug use disorders were less or more likely to perceive a need for treatment. That is, results of the bi-variable analyses show that respondents with hallucinogen or marijuana use disorders were less likely to perceive a need for treatment; whereas, respondents with analgesic, cocaine or stimulant use disorders were more likely to perceive a need for treatment. When controlling for socio-demographic and other factors analgesic, stimulant, and marijuana use disorders were no longer associated with perceiving a need for treatment suggesting that the association may be mitigated by other controlled factors. Multivariable results also indicated that among respondents that needed treatment for drug use disorder, those with hallucinogen use disorder were less likely to perceive a need for treatment; whereas, respondents with cocaine use disorder were more likely to perceive a need for treatment. Similarly, among respondents with both an alcohol and drug use disorder, bivariable analysis suggest that respondents with analgesic, cocaine, sedative/tranquilizer, or stimulant use disorder were more likely to perceive a need for treatment; whereas, respondents with a marijuana use disorder were less likely to perceive a need for treatment. When controlling for other variables, respondents with a stimulant use disorder were more likely to perceive a need for treatment. Overall results suggest that certain disorders are less or more likely to be perceived as disorders that are necessary for treatment with respondents with cocaine or stimulant use disorders independently associated with perception of treatment need among respondents with drug use disorders or both alcohol and drug use disorders, respectively. Future research may want to delineate perceived need by particular drug classification in order to determine whether characteristics of perceiving a need for treatment may be distinguished among individuals with a specific drug use disorder. Limitations of this study should be noted; the NSDUH has a cross sectional design. Future research may want to follow respondents

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prospectively over time in order to determine individual changes in perceiving a need for treatment. Also, the NSDUH study is based on retrospective, self-reported data and could be affected by problems with recall or reporting biases. Participants may under or over report their drug use compared to treatment seeking individuals or due to stigmas associated with mental health and drug use (Harrison, 1997). In order to increase the level of honest reporting of illicit drug use and other sensitive behaviors, the NSDUH incorporated audio computer assisted self-interviewing (ACASI) technology by providing participants with a private and confidential way of responding to sensitive questions (Epstein, Barker, & Kroutil, 2001). Role of funding sources None. Contributors Sarra L. Hedden wrote the first draft of the manuscript and ran the analyses. Joseph C. Gfroerer conceptualized the manuscript and made revisions to the draft. Conflict of interest The authors have no conflicts of interest to disclose.

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