Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation.

Background: Little is known about the stability of public drug treatment in the United States to deliver services in an era of expansion of public insurance. Guided by organizational theories, we examined the role of program size, and performance (i.e., rates of treatment initiation and engagement) on discontinuing services in one of the largest treatment systems in the United States.

Methods: This study relied on multi-year (2006-2014) administrative data of 249,029 treatment admission episodes from 482 treatment programs in Los Angeles County, CA. We relied on survival regression analysis to identify associations between program size, treatment initiation (wait time) and engagement (retention and completion rates) and discontinuing services in any given year. We examined program differences between discontinued versus sustained services in pre- and post-expansion periods.

Results: Sixty-two percent of programs discontinued services at some point between 2006 and 2014. Program size and rates of treatment retention were negatively associated with risk of discontinuing services. Proportion of female clients was also negatively associated with risk of discontinuing services. Compared to residential programs, methadone programs were associated with reduced likelihood of discontinuing services. Two interactions were significant; program size and retention rates, as well as program size and completion rates were negatively associated with risk of discontinuing services.

Conclusions: Program size (large), type (methadone), performance (retention) and client population (women) were associated with stability in this drug treatment system. Because more than 70% of programs in this system are small, it is critical to support their capacity to sustain services to reduce existing disparities in access to care. We discuss the implications of these findings for system evaluation and for responding to public health crises.