Changes in Admissions to Specialty Addiction Treatment Facilities in California During the COVID-19 Pandemic

The COVID-19 pandemic was associated with increased risk of substance use and a surge in fatal drug overdoses.^1,2 However, little is known about how the pandemic affected addiction treatment utilization.^3,4 This study evaluated how the initiation of addiction treatment in California changed during the pandemic. We focused on specialty addiction treatment programs because that is where most people receive care for addictions.⁵

This cohort study received approval and a waiver of informed consent from the New England IRB and the University of California, Los Angeles, institutional review board. Informed consent was waived because data were deidentified. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

This cohort study used data from the 2019 and 2020 California’s Outcomes Measurement System. Alcohol and drug treatment organizations licensed by the California Department of Health Care must collect demographic and medical history information from all patients at treatment initiation using standard data collection forms. Initiation included admission to either inpatient or outpatient treatment programs. California reviews the data to ensure completeness and accuracy. Because of data reporting lags, some California counties had missing data for some months between June and October 31, 2020. The eMethods and eTables in the Supplement provide details on missing data and imputation methods.

We identified January 1, 2019, through February 29, 2020, as pre–COVID-19 months and March 1, 2020, to October 31, 2020, as post–COVID-19 months. We estimated linear regressions to calculate the statistical significance of the percentage change in treatment initiations pre– and post–COVID-19 using Stata statistical software version 16.1 (StataCorp). The dependent variable was the ratio of the month’s total initiations to the mean initiations per month over the pre–COVID-19 period. To determine if the percentage change in treatment initiations differed by subpopulations, we added an interaction term between the pre– and post–COVID-19 period and the population characteristic. P values were 2-sided, and statistical significance was set at P < .05. Data were analyzed from December 2020 through March 2021.

The total number of treatment initiations was 237 835 before imputation and 247 566 after imputation. During the COVID-19 period, monthly initiations were 28.3% (95% CI, −34.9% to −21.7%) lower than they were pre–COVID-19, with mean (SD) monthly initiations of 8994 (713) patients vs 12 544 (920) patients (Figure). The percentage decline in initiations was similar by setting, sex, race, ethnicity, education, whether the patient had children younger than age 18 years, veteran status, and whether the patient was hospitalized before treatment initiation (Table). Larger declines in initiations occurred among individuals without Medicaid coverage (−10.8%; 95% CI, −20.5% to −1.1%), younger than 25 years (compared with those age 25 to 44 years: −15.6%; 95% CI, −25.7% to −5.6%), who were employed (−11.6%; 95% CI, −22.1% to −1.1%), with dependent living (−11.4%; 95% CI, −21.6% to −1.3%), with social supports (−11.8%; 95% CI, −21.4% to −2.2%), without mental illness (−10.5%; 95% CI, −20.0% to −1.1%), with cannabis as the primary drug of abuse (−21.6%; 95% CI, −31.9% to −11.2%), with criminal justice involvement (−13.1%; 95% CI, −22.6% to −3.7%), who had been recently released from prison (−15.9%; 95% CI, −29.6% to −2.2%), who were referred from a driving under the influence program or drug court (–11.5%; 95% CI, –21.9% to –1.1%), or who were referred from another community source (ie, community, child protective services, employer, and self-referral) (−16.1%; 95% CI, −26.5% to −5.7%).

This cohort study found that the COVID-19 pandemic was associated with a 28% decline in addiction treatment initiations through October 2020. Other research that has examined the association of the pandemic with the use of medical services reported minimal declines in receipt of nonelective procedures and prescriptions but large decreases in receipt of preventive and elective procedures.⁶ Individuals may have been reluctant to seek addiction treatment for fear of becoming infected with SARS-CoV-2. Greater outreach and assurance about the safety of treatment during the pandemic may have allayed these concerns. The decline may also reflect the inability of addiction treatment organizations to treat as many patients as before the pandemic. More rapid and robust government intervention to facilitate the acquisition of personal protective equipment, telehealth equipment, additional staff, and space to deliver socially distanced services may have helped maintain access. Additionally, courts reduced operations during the pandemic, and prisons expedited the release of nonviolent offenders because of the risk of COVID-19 in crowded prison environments. The criminal justice system may need better procedures to connect individuals to addiction treatment during public health emergencies. One limitation of this study was that it only includes specialty addiction services in California; therefore, these findings may not be generalizable and should be replicated using additional states and data from nonspecialty settings. Research is also needed to understand the cause of the decline in initiations and the extent to which it was due to reduced demand for services or reduced ability to supply treatment.

Accepted for Publication: May 6, 2021.

Published: July 14, 2021. doi:10.1001/jamanetworkopen.2021.17029

Correction: This article was corrected on May 31, 2023, to fix an error in the Table column headers and add clarification on the unit of analysis.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Mark TL et al. JAMA Network Open.

Corresponding Author: Tami L. Mark, PhD, MBA, RTI International, 6110 Executive Blvd, Ste 900, Rockville, MD 20852 (Tmark@rti.org).

Author Contributions: Dr Joshi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mark, Gibbons, Barnosky, Padwa.

Acquisition, analysis, or interpretation of data: Mark, Gibbons, Joshi.

Drafting of the manuscript: Mark, Gibbons, Barnosky, Joshi.

Critical revision of the manuscript for important intellectual content: Mark, Gibbons, Barnosky, Padwa.

Statistical analysis: Mark, Gibbons, Barnosky, Joshi.

Obtained funding: Mark.

Administrative, technical, or material support: Mark, Padwa.

Supervision: Mark.

Conflict of Interest Disclosures: No other disclosures were reported.

Funding/Support: Research reported in this study was funded through a Patient-Centered Outcomes Research Institute award (contract No. HIS-2017C1-6371).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The results and the conclusions are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its Board of Governors, or its Methodology Committee.

Additional Contributions: Minerva Reyes and Alicia Van Hoy (California Department of Health Care Services) provided the data in used in this study. They were not compensated for this work.