Where is the 'where?' in considerations of treatment for drug abuse?

Substance abuse has been a major urban health problem, and in response, drug abuse treatment programs have been developed. Retention in programs is key to their effectiveness, yet attrition is a well recognized problem in this area. Most of the research on drug treatment programs attrition/retention rates examined individual level factors of the patients in treatment and less so provider level. Data on possible ecological or neighborhood factors relating to attrition/retention are sparse. However, such factors would seem promising to consider as neighborhood-level investigations have identified factors that influence illicit drug use. For example, a recent study reported that neighborhood disadvantage is an independent predictor of drug use, especially for individuals with lower incomes.1 In this issue of the Journal of Urban Health, Jacobson extends conceptual thinking about contextual factors that may influence drug treatment retention2 and undertakes the first quantitative exploration assessing “appropriateness” of treatment locations.3 In the study, Jacobson identifies neighborhood-level disadvantage, violence and victimization, and drug activity as elements with likely influence on treatment attrition. To do this, he compared measures of these factors for public treatment facility locales in the city of Los Angeles with those for the residential neighborhoods of the patients enrolled in treatment. Jacobson reported that up to 20% of patients are receiving drug treatment in an area that has a greater risk profile than the place in which they reside. Still, the question remains as to whether the patients that attend treatment in more disadvantaged locations than those in which they reside have worse treatment outcomes than those whose residential locations are equivalent to or worse than their treatment locations. Further research is clearly necessary in order to more fully understand the treatment location–treatment outcome dynamic. Nonetheless, Jacobson’s results can have important policy implications by renewing discussion and debate about appropriate placement for drug abuse treatment programs. On the one hand, locating drug treatment facilities in more advantaged neighborhoods has the potential for a positive impact on patient outcomes. First, fewer patients would be going to drug treatment in locations that have worse measures of neighborhood context than their current residences. Second, Jacobson finds that currently the average patient is 2.6 and 2.7 times more likely to both attend treatment in and live in a disadvantaged neighborhood than the average non-patient, respectively. Continuation of drug use is related to contextual cues; removing users from their environment would likely result in better outcomes. Yet, as people return to their communities of residence after treatment, whether treatment placement can have any impact remains an open question. On the other hand, placing treatment facilities in more advantaged neighborhoods may be problematic for several reasons. For instance, residents and businesses in those areas may resist the incorporation of the program because they believe that an increased flow of drug users to their neighborhood will also increase drug activity and availability or other socially undesirable activities in their neighborhood, even though the patients are seeking treatment (also known as the “not in my backyard” phenomenon). Also, studies have shown that travel distance can be a factor in treatment attrition;4 therefore, if patients are concentrated in disadvantaged areas that are isolated from more advantaged areas, placing facilities in these less disadvantaged areas may be more counterproductive in the long run. Planning committees would need to ascertain, assess, and alleviate transportation barriers for clients, but this may be cost prohibitive. Although this study was in one urban area only, and further research is warranted, the findings are provocative and merit policy discussion. Treatment programs represent an important strategy to deal with the problem of substance abuse, and the role of program placement in facilitating the goal of optimizing treatment is an important topic in this discussion.