Going Without

Substance use and addiction impact the health of Coloradans across the state, and many of them don’t get the treatment they need, according to new findings from the 2019 Colorado Health Access Survey (CHAS). 

Between 2017 and 2018, 11.9% of people 18 and older in Colorado reported a substance use disorder in the past year, higher than the national rate of 7.7%. Connecting people to treatment is key to addressing drug and alcohol addiction and preventing overdose deaths. 

However, many Coloradans are unable to access necessary services for substance use disorders. According to the 2019 CHAS, over 95,000 Coloradans 18 and older (2.3%) did not get treatment or counseling to address their dependencies. 

Why is that? Coloradans cite several reasons, including the stigma associated with substance use or dependence, the cost of services, and inadequate insurance coverage. Stigma is a particular challenge. Between 2017 and 2019, there was a significant increase in the percentage of people who reported stigma as a reason they did not get substance use services.

There are disparities in who gets needed substance use treatment and counseling services across Colorado. Data from the CHAS provide a deeper look into these differences to illuminate who is at greater risk of not getting substance use treatment services when they need them.

Increased access to treatment and counseling has been a focus for policymakers as the opioid crisis has gripped the nation over the last 10 years. However, due to the impact of COVID-19 on Colorado’s economy, many substance use treatment programs and services face major budget cuts. On the flip side, changes in health care policy and telemedicine innovations made in the wake of the pandemic have expanded access to some services. All of these factors have the potential to change Coloradans' access to substance use treatment in the coming years.  

Coloradans Who Do Not Get Needed Substance Use Treatment Services 

The CHAS helps paint a picture of who in Colorado is more likely to not get the services they need for a substance use disorder (see Figure 1). 

Of those who did not get needed services, the majority were under the age of 40 (62.6%). More than half were between the ages of 24 and 39. They were also more likely to be male (74.9%) and had lower incomes than the general population of Colorado. This group did not have differences in racial makeup compared to Colorado’s overall population.

Why Don’t Coloradans Seek Needed Substance Use Treatment Services?

Stigma surrounding substance use is a major deterrent for people who are thinking about getting help. They may worry what others will think if their dependence on alcohol or drugs is discovered or could be embarrassed to talk about the problem with counselors or doctors. These feelings often negatively impact a person’s chance of seeking treatment and recovering from their addiction.

It’s not surprising that so many Coloradans are concerned about stigma. The public — and many health professionals — view substance use as a reflection of character instead of as a complex medical condition influenced by many social and economic factors like housing, income, and social connectedness.  For example, most Americans (78%) believe that individuals with an opioid addiction are to blame for their substance use problem.

Between 2017 and 2019, the CHAS recorded a statistically significant increase in the percentage of Coloradans who did not get needed substance use treatment services because of stigma. Of those who reported they did not get help in 2019, 72.8% said that they were not comfortable talking with a health professional about personal problems, up from 41.3% two years prior (see Figure 2). Similarly, there was a sizable jump in the proportion of Coloradans who did not seek out treatment services because they were worried about what would happen if someone found out they had a problem, increasing to 72.4% in 2019 from 43.9% in 2017. 

Some of the increase could be attributed to a change in the methodology of the CHAS, which switched from a phone interview format in 2017 to an online survey in 2019. This shift may have made people more comfortable reporting circumstances around substance use, providing a clearer portrait of the problem and greater insight into barriers to treatment services.

Reducing stigma can improve access to care, and in some cases, the quality of care for people who are seeking treatment.

Cost and Other Barriers to Care Make It Difficult to Get Needed Substance Use Treatment

Cost, access to care, and insufficient insurance coverage are also barriers to care. More than half of those who did not get needed services reported they did not think their health insurance would cover it (Figure 3). Another 47.7% did not get services due to cost. Additionally, nearly a third of those who did not get treatment said it was because they had a difficult time getting an appointment. Some Coloradans may not get services because they  lack insurance. 

Of those who did not get treatment services, more than one in five were uninsured (21.8%). The cost of substance use treatment and counseling varies widely based on level of care needed and duration of care. Even those with private insurance aren’t always able to access behavioral health services. A new report from Milliman shows that Coloradans have to go out of network more often for behavioral health services compared to physical health services, which can lead to higher costs for those seeking treatment.

What Disparities Exist in Colorado

To understand which groups struggle to access needed substance use treatment services, data from the 2017 and 2019 survey years of the CHAS were combined to create adequate sample sizes for analysis.

Access to Substance Use Treatment Services: A Generational Challenge

Millennials (born between 1981 and 1996) were more than twice as likely to report needing but not getting treatment services compared with Generation Xers (born between 1965 and 1980) and post-millennials (born between 1997 and 2014). They were also nearly six times more likely than baby boomers (born between 1946 and 1964) to report needing but not getting substance use treatment services (see Figure 4).

It may be that millennials stand out because they do not have or cannot afford coverage. More than one in 10 people in this age group are uninsured (11.7%) compared with 5.3% of Coloradans of other ages. This may lead them to think they cannot afford treatment, although options are often available, including services through Managed Service Organizations (MSOs) contracted by the Colorado Office of Behavioral Health. Additionally, millennials may also be more comfortable than older Coloradans saying they need substance use treatment services, which may also increase the rate who report not getting care.⁸

Men Were More Likely to Go Without Needed Services

Men were more likely to report needing but not receiving substance use treatment or counseling services than women in Colorado (3.0% compared with 1.0%). Despite perceptions that men may be more reluctant to seek treatment due to societal expectations, a higher percentage of women reported being concerned if someone found out they had a substance use problem (68.5%) compared with men (57.1%), although this difference wasn’t statistically significant.

The variation may be attributed to differences in use between men and women. Research has shown that men are typically more likely to use illicit drugs and begin to use alcohol and drugs at a younger age than women. Men are also more likely to drink excessively, putting them at risk for higher rates of alcohol-related deaths. Women may be less likely to report needing help due to stigma, in part because of potential involvement with human service systems such as child welfare if they have children.

Those With Lower Incomes Were More Likely to Report Not Getting Needed Services

Coloradans with incomes at or below 200% of the federal poverty level were more than twice as likely to report not getting needed substance use services compared with higher-income respondents (3.3% compared with 1.4%).

Coloradans with lower incomes have a harder time affording treatment. A coverage gap does exist for those whose incomes are too high to be eligible for Medicaid, but who can’t afford health insurance through their employer. At the same time, having health insurance does not always guarantee access to services. As seen in the report from Milliman, many Coloradans get behavioral health services through providers who aren’t covered by their insurance networks.

Different Race/Ethnicity Groups Reported Similar Rates of Needing but Not Getting Services

There was no significant difference between racial or ethnic groups needing but not getting substance use treatment services. About 2.0% of Coloradans age 18 and older who are Hispanic/Latinx reported needing but not getting substance use treatment services, compared with 1.8% of those who are white (non-Hispanic/Latinx). (Other racial and ethnic groups, such as Coloradans who identify as Black or African American, had sample sizes too small to report.)

Results of studies examining how race and ethnicity impact engagement with substance use treatment services have varied. Some studies have shown lower rates of initiating treatment among those who are Black or Hispanic/Latinx. However, many factors impact people’s ability to get treatment, including access to transportation and child care, stable housing, and unemployment, among others.

Social Isolation, Telehealth, and Access: How COVID-19 Has Reshaped Behavioral Health

Because of the COVID-19 pandemic, many more Coloradans are faced with social isolation and increased stress brought on by layoffs, loss of health insurance, and other factors. These stressors can impact behavioral health in many ways and may fuel an increased demand for behavioral health services.

The economic fallout of the pandemic can be an intense stressor. Research has shown that job loss is associated with mental health issues such as depression and anxiety, which may lead to higher rates of substance use. Between March 21 and June 20, 2020, more than 550,000 Coloradans filed for unemployment.

In addition to the staggering number of COVID-19 fatalities across the nation, experts are worried about what are called “deaths of despair” as the economic and social crisis continues. These are deaths attributed to drugs, alcohol, or suicide, and are often traceable to socioeconomic factors like unemployment. Experts have predicted between 27,644 and 154,037 additional deaths of despair nationally because of the impact of COVID-19 based on various scenario analyses. Colorado is anticipated to experience an increased burden of  “deaths of despair” in the coming years due to the pandemic.

The pandemic also creates a new set of obstacles for those seeking or those currently enrolled in treatment programs. Certain treatment protocols for medication-assisted treatment, for example, require frequent visits to clinics to receive necessary medications like methadone. 

To address this issue, the U.S. Department of Health and Human Services has eased regulations to allow those with substance use disorders to take home medications that will last a longer period. Additionally, the Substance Abuse and Mental Health Services Administration (SAMSHA) has updated rules so that a third-party individual may pick up and deliver prescriptions to a person’s home. 

Expansion and innovation of telehealth and telemedicine services could be one way to combat not just isolation but also issues surrounding access to treatment and care. However, telehealth services might not reach the most vulnerable populations. People who suffer from substance use disorders are more at risk of experiencing homelessness and are more likely to be incarcerated.²⁰ Because of this, many experts argue that investments in programs to reach these populations are crucial during this time of uncertainty. Due to budget cuts in in the wake of the pandemic, however, some of these programs could face serious setbacks. 

Policy Implications and Funding Cuts in the Wake of COVID-19

The economic fallout of the pandemic is immense. Hundreds of thousands of Coloradans have lost their jobs, and the state general fund shrunk by over $3 billion in fiscal year 2020-2021. Although 1.7 billion in federal aid has come to Colorado, the state will experience major cuts in areas like human services, education, health care, and public health.

Many behavioral health programs are bracing for a hit. Over $13 million for substance use programs has been cut from the state budget to help bridge the shortfall. Some of these cuts include over $1 million will be cut from medication-assisted treatment programs in county jails, while another $1.8 million will come out of Tony Grampsas grants, which are meant to help prevent youth crime and substance use. Many cuts were strategic and affected areas that were underspent or new programs, in an effort to reduce the impact on existing services. Federal dollars and additional grant funding will also help alleviate some of the strain. Still, cuts to these programs and others are likely to impact people with low incomes and those who already face barriers to care.

Conclusion

In 2019, many Coloradans were still not getting the treatment they needed for substance use and dependence. Those who are younger, male, and have lower incomes were particularly likely to go without needed care. In 2020 and beyond, pandemic-related budget cuts are impacting many substance use treatment and recovery programs. However, rapid changes in telemedicine may assist in gaps of service access, providing new modes of service delivery during this unprecedented time.