March 19th, 2012
By Dr. Adi Jaffe and Tariq Shaheed
How annoying is it to be running late for work unable to find your keys, wallet, or coveted smart phone? You check under the bed, between the sofa cushions, and in your useful phone valet, before giving up and calling in late to work (if it’s not your phone you’re missing). You ask your wife, who says she hasn’t seen it, and your child, who thinks it’s under the bed (you’ve looked, it’s not). Finally, giving up, you go to your car, where your phone sits smugly right on the passenger seat. As troubling and frequent as this story might be, it’s nothing compared to the difficult experience of over 20 million Americans who annually look for addiction treatment but don’t find it . So what’s keeping so many Americans out of treatment?
Internal and external barriers to addiction treatment entry
In a study done in 2008, researchers surveyed a sample of 518 subjects varying in race and age, to find out about the barriers keeping them out of addiction treatment.  The study was conducted in Montgomery County Ohio, was a part of nationally funded “Drug Barrier Reduction” effort lead by the National Institute on Drug Abuse (NIDA). Most participants were using crack (38.4%), heroin (25.1%), marijuana (14.9%), and alcohol (11.2%). The researchers found a number of internal and external barriers that keep drug abusers from getting the help they need. Internal barriers included stigma, depression, personal beliefs, and attitudes about treatment, while external barriers (systematic or environmental circumstances that are out of a person’s control) include time conflicts, addiction treatment accessibility, entry difficulty, and cost of addiction treatment. 
The researchers concluded that both internal and external barriers can be addressed and improved, but that eliminating the external barriers to addiction treatment is most feasible and could substantially decrease the number of untreated addicts in the United States. Since addressing an internal barrier like “believing one can quit at anytime” (accounts for 29.3% untreated Americans) still requires the ability of the substance user to get treatment, it seems that addressing external triggers will be more immediately effective. Just as motivation to find an item such as keys, phone, or wallet is not the only factor in obtaining that item, a substance user with no internal barriers to treatment is still constrained by all those external barriers, and still not in substance abuse treatment.
The most commonly cited external barriers in the study were:
- Time conflicts – being unable to get off work for treatment, household obligations, busy schedules and simply not having time for substance abuse treatment.
- Treatment accessibility - living too far away for treatment, not knowing where to go for treatment, having difficulty getting to and from treatment, and not understanding the addiction treatment options. Subjects reported that being wait-listed for a facility, and having to go through to many steps contributed to deterring them from seeking treatment.
- Financial barriers included inability to pay for treatment and being uninsured.
Some common internal barriers include:
- Stigma associated with the label of being call an alcoholic or an addict, or stigma regarding addiction treatment. Thus being unwilling to share problems and ask for help.
- Psychological distress such as depression and neuroticism which produces a lack of motivation among substance abuse treatment seekers.
- Personal beliefs
- Religion- God will remove the addiction at the right time
- Denial – User doesn’t believe they are an addict
- Doesn’t need treatment – For example 30% of heroin abuser believed they would recover without treatment.
Although getting substance abusers help is difficult, it starts by understanding the nature of the problem. While one person may not believe they are addicted, another may not understand how sliding scale payment for treatment works. Different individuals may need different helpful resources when it comes to understanding their options.
Thoughts and limitations regarding the research
As we pointed out in a recent article, it’s important to know who is participating in addiction research. In this case, the individuals recruited were reporting for substance abuse treatment assessment at a county intake center. This means the clients are likely from relatively low Socioeconomic Status (SES) groups, but also that they are for some reason motivated to find treatment. Those reasons themselves could be internal (decided to make a change) or external (got arrested), but it’s important to know that these findings do not necessarily apply to more affluent, insurance carrying, or addiction treatment uninterested, individuals. We are currently in the process of conducting a more general study to assess needs in that group.
Also, the time and costs constraints identified by participants can often be overcome by increasing flexibility in searches and by better tailoring the treatment referrals (see our Rehab Finder articles). Costs can be reduced while saving time by looking into outpatient, rather than residential, treatment options. Unfortunately, Americans have been exposed only to the residential treatment model (a la the Dr. Drew and Intervention television shows), but outpatient addiction treatment is effective, costs less, and truly a better fit for many clients (especially those still working, attending school, etc.).
Finally, not all of the internal beliefs can be written off as unreasonable barriers – indeed, it is likely that most individuals who do not seek official substance abuse treatment, and certainly most of those who never enter official substance abuse treatment, will still recover from their addiction without it. As we pointed out in previous articles (see here, and here), most people who use drugs do recover and many do it with no treatment per se, especially when looking at our biggest substance abuse problem – alcohol. That means that some people termed “in denial” and “not needing treatment” were actually either correct, lucky, or both. Recovery doesn’t have to look like we expect it to, it just has to result in a person who is no longer suffering with addiction.
A3 Plug (you knew it was coming)
At A3 we believe information is the key; by dispelling myths about addiction, removing stigma and anonymity, reviewing the latest research in treatment, and finding 21st century solutions to barriers, we hope to reduce the number of untreated. Join us in the fight to educate and treat addiction.
1. Jiangmin Xua; Richard C. Rappa; Jichuan Wanga; Robert G. Carlsona. (2008) The Multidimensional Structure of External Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.
2. An investigation of stigma in individuals receiving treatment for substance abuse