Perceived Barriers to Treatment Entry and Retention Among Opiate Users in Skid Row, Los Angeles

Background and Purpose: Skid Row, located in downtown Los Angeles contains the largest concentration of individuals experiencing homelessness in the United States. In the service planning area where Skid Row is located drug overdose was the second leading cause of premature death. While alcohol consumption among homelessness populations has been historically documented (Bahr & Caplow, 1974; Bogue, 1963; Rice, 1918; Straus, 1946) the use and abuse of other illicit drugs (Dennis, Bray, Iachan, & Thornberry, 1999; Fisher & Breakey, 1991; Johnson & Barrett, 1995; Lehman & Cordray, 1993; O’Toole et al., 2004; Stark, 1987) including injection drug use (Aidala et al., 2005; Bourgois, 1998; Briggs et al., 2009; Roy et al., 2010; Song et al., 2000) has been acknowledged in more recent research. Substance use patterns and risks may be further influenced by the high incidence of chronic pain among homeless persons and barriers to obtaining health care (Hwang et al., 2011; Fisher et al., 2013), which may lead to the self-medication of pain through injecting heroin, and obtaining prescription pain medication from the street (Voon et al., 2014).  Substance abuse treatment completion for homeless individuals can be difficult due to a limited social support paired with housing instability and drug dependence trajectories (Galanter et al., 2004; Kertesz, Horton, Friedmann, Saitz, & Samet, 2003). This qualitative study was conducted to explore perceptions on opiate addiction treatment among a diverse group of opiate users receiving services from a harm reduction center in Skid Row.

Methods: Using venue based recruiting focus groups were conducted with 50 individuals receiving services from a harm reduction center located in Skid Row in Los Angeles. Individuals over the age of 18 who reported illicit use of prescription opiates in the past year were eligible for participation. Using an inductive thematic approach the transcripts were coded into general and specific themes. The University of Southern California Institutional Review Board approved all data collection methods.

Results: The mean age of participants was 43.5 years and the majority of participants identified as male and Hispanic. Most respondents were unemployed and experiencing residential instability. Themes of treatment entry and retention emerged. For treatment entry participants identified waiting lists and limited program space. Treatment retention barriers included experiences of stigma from treatment providers, family related concerns and obligations, motivation to change, and program requirements. Recommendations for improving access to treatment included inpatient treatment options, assistance in transportation, and access to housing. Treatment retention recommendations included expansion of services such as specialized case management, integrated care, and mental health care.

Conclusions and Implications: While much of the current focus on the opiate epidemic has centered on primarily white, middle-class and rural populations, it is important to understand the perspectives of urban historically marginalized individuals. Understanding perceived barriers and recommendations for improving access to and retention in treatment from the perspective of patients/clients can translate into more effective patient-centered care.