April 22, 2010

Puerto Rican Admissions to Substance Abuse Treatment

Substance abuse by Hispanics is of special concern because of the rapid growth of this population. The number of Hispanics in the United States increased from about 35 million in 2000 to 44 million in 2006 and is projected to more than double to nearly 103 million by 2050.¹ Hispanics of Puerto Rican background were the second largest Hispanic group in the United States in 2007 (4.1 million), after those of Mexican background (29.2 million).² Although Hispanics are commonly grouped together in a single category of ethnicity, this group is not homogenous, consisting of individuals who self-identify by country of origin, such as (but not limited to) Puerto Rican Hispanics, Cuban Hispanics, or Mexican Hispanics. The distinctions among these groups are important culturally and linguistically and may be reflected in differing patterns of substance use and abuse. This report focuses on admissions for Puerto Rican Hispanics.

Recent findings from the National Survey on Drug Use and Health showed that 3.4 percent of the Hispanic population in the United States (1.1 million people) aged 12 or older needed treatment for illicit drug use, but only 15.1 percent of those in need had received treatment at a specialty facility. Hispanics of Puerto Rican background were more likely to need treatment for illicit drug use than those of other Hispanic ancestry.³

The Treatment Episode Data Set (TEDS) collects information on the race/ethnicity of substance abuse treatment admissions, and on the ethnic origin of those who report that they are Hispanic. Using 2007 data from TEDS (including admissions in 44 States, the District of Columbia, and Puerto Rico), this report examines the characteristics of Puerto Rican admissions and compares these with all other Hispanic admissions not identified as Puerto Rican. For this report, Hispanic admissions that were not identified as Puerto Rican are referred to as "other Hispanic admissions."⁴ In 2007, there were approximately 70,700 Puerto Rican substance abuse treatment admissions, representing 4.0 percent of TEDS admissions and 26.5 percent of TEDS admissions of Hispanic origin in the States and jurisdictions used in this report.

Primary Substances of Abuse

Heroin was the most common primary substance of abuse among Puerto Rican substance abuse treatment admissions (43.5 percent), while alcohol was the most common substance of abuse among other Hispanic admissions (36.9 percent) (Table 1). Puerto Rican admissions were more than three times as likely as other Hispanic admissions to report primary abuse of heroin (43.5 vs. 13.2 percent). Both Puerto Rican male and female admissions were more likely than their other Hispanic counterparts to report primary abuse of heroin (45.3 vs. 13.9 percent for male admissions and 36.0 vs. 11.3 percent for female admissions). Puerto Rican admissions were about 16 times less likely than other Hispanic admissions to report primary abuse of methamphetamine (0.9 vs. 16.2 percent). In particular, more than 1 in 4 other Hispanic female admissions reported primary abuse of methamphetamine compared with about 2 percent of Puerto Rican female admissions.

Among Puerto Rican admissions for primary abuse of heroin, more than two thirds also reported the secondary or tertiary abuse of other substances (68.6 percent), including 47.0 percent that reported secondary or tertiary abuse of cocaine (Figure 1). Female Puerto Rican heroin admissions were somewhat more likely than their male counterparts to report secondary or tertiary cocaine abuse (53.6 vs. 45.8 percent).

Over half of Puerto Rican admissions for primary abuse of heroin (55.9 percent) reported injection as the usual route of administration. An additional 42.3 percent reported inhalation (i.e., “snorting”). Less than 2 percent reported other routes of administration.

Admissions by Geographic Characteristics

More than 85 percent of Puerto Rican admissions took place in States in the Northeast (Figure 2).⁵ This finding is consistent with U.S. Census Bureau data which indicate that, after Puerto Rico, the largest number of Puerto Ricans lived in the Northeast in 2007.² More than four fifths of all Puerto Rican admissions were in four Northeastern States: New York (58.3 percent), Massachusetts (8.8 percent), New Jersey (8.3 percent), or Connecticut (6.5 percent). An additional 5.1 percent of Puerto Rican admissions were in substance abuse treatment programs in Puerto Rico.

Demographic Characteristics

Most Puerto Rican and other Hispanic admissions were male, though the proportion was somewhat higher among Puerto Rican admissions (80.6 vs. 72.2 percent) (Table 2). Overall, Puerto Rican admissions were older than other Hispanic admissions. The majority (57.8 percent) were aged 35 or older at the time of admission compared with 39.9 percent of other Hispanic admissions. In addition, Puerto Rican admissions were about half as likely as other Hispanic admissions to be under the age of 25 (14.3 vs. 31.8 percent). Puerto Rican admissions also were more likely than their other Hispanic counterparts not to be in the labor force at the time of admission (58.6 vs. 37.3 percent) and were about half as likely as other Hispanic admissions to be employed (15.8 vs. 32.9 percent).

These differences between Puerto Rican and other Hispanic admissions appeared to be due to the high percentage of admissions for primary heroin abuse among Puerto Rican admissions. Specifically, 66.1 percent of Puerto Rican primary heroin admissions were aged 35 or older, and only 4.8 percent were under the age of 25. Similarly, 62.2 percent of Puerto Rican primary heroin admissions were not in the labor force and only 10.0 percent were employed at admission.

Prior Treatment and Source of Referral

Most Puerto Rican admissions to treatment (70.5 percent) had at least one prior treatment episode, but most other Hispanic admissions (41.7 percent) did not (Table 2). In addition, Puerto Rican admissions were nearly three times as likely as their other Hispanic counterparts to have had five or more prior admissions (18.6 vs. 6.6 percent). Individual or self-referrals were the most common referral source among Puerto Rican admissions (42.4 percent), while criminal justice system referrals were the most common among other Hispanic admissions (44.8 percent).

Type of Service and Medication-assisted Opioid Therapy

Puerto Rican admissions were four times as likely as other Hispanic admissions to be admitted to a hospital setting to receive 24-hour per day medical acute care services for detoxification (13.2 vs. 3.3 percent) (Table 3); this service setting is intended for persons with severe medical complications associated with withdrawal. In turn, Puerto Rican admissions were less likely than their other Hispanic counterparts to receive outpatient (46.8 vs. 56.4 percent) or intensive outpatient treatment (5.4 vs. 9.1 percent).

Among primary heroin admissions, those that were Puerto Rican were somewhat more likely than those in other Hispanic groups to be admitted to hospital detoxification (15.8 vs. 10.8 percent). In addition, medication-assisted opioid therapy with methadone or buprenorphine was planned for a lower percentage of Puerto Rican primary heroin admissions (32.9 percent) compared with their other Hispanic counterparts (41.8 percent).

Discussion

Findings from this report underscore the different service needs among Puerto Rican admissions to substance abuse treatment compared with their other Hispanic counterparts. In particular, Puerto Rican clients' access to appropriate services is an important issue for policymakers and treatment and prevention providers in jurisdictions with large Puerto Rican populations in several respects. First, cultural competence is more than the language used in treatment or in prevention strategies. It consists of culturally appropriate messaging, outreach and engagement, and the provision of acceptable therapeutic interventions.⁶ Second, identifying heroin as a common primary substance of abuse among Puerto Rican admissions highlights the need to address the medical screening, health education, and primary care needs among these admissions, especially for those who are injectors.

In addition, the findings for prior treatment episodes and admissions to hospital detoxification also suggest that Puerto Rican admissions may present with more severe complications of substance abuse compared with their other Hispanic counterparts. Therefore, policymakers and program directors may need to consider strategies for effectively addressing the severity of Puerto Rican clients’ substance abuse. Finally, the lower likelihood of medication-assisted opioid therapy being planned for Puerto Rican primary heroin admissions compared with other Hispanic heroin admissions suggests the need for strategies to ensure Puerto Rican heroin abusers’ transition from detoxification to other treatment services, additional strategies to prevent relapse during treatment, or different, more targeted types of support during the aftercare period.

End Notes

¹ U.S. Census Bureau. (n.d.). Hispanics in the United States. Presentation created by the Ethnicity and Ancestry Branch, Population Division. (Available as a PDF at http://www.census.gov/population/www/socdemo/hispanic/files/Internet_Hispanic_in_US_2006.pdf)
² Source: 2007 American Community Survey (ACS). Data tables for the 2007 ACS are available from the American FactFinder link on the 2007 ACS Data Release Web page (http://www.census.gov/acs/www/Products/2007/index.html)
³ Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009, July 16). The NSDUH Report: Substance use treatment need and receipt among Hispanics. Rockville, MD.
⁴ Valid Hispanic ethnicity codes included "Puerto Rican," "Mexican," "Cuban," "Other specific Hispanic," "Hispanic (specific origin not specified)," and "Not of Hispanic origin." Approximately 1.3 percent of all TEDS admissions did not have a valid Hispanic ethnicity code. TEDS admissions from New Hampshire were excluded from the analysis for this report because of miscoding in their Hispanic ethnicity data, and admissions for Alabama, Alaska, Georgia, Mississippi, and West Virginia were not reported for 2007. In addition, five States (Arizona, Louisiana, Oklahoma, Rhode Island, and Wisconsin) report admissions to TEDS as Hispanic or not Hispanic but do not report Hispanic ethnicity by subgroup. Hispanic admissions from these latter five States were included in the analysis and were treated as not being Puerto Rican. For brevity, Hispanic admissions in this report that were not identified as Puerto Rican are referred to as other Hispanic admissions.
⁵ The 45 States and jurisdictions that provided TEDS data for this report fall into the following U.S. Census Bureau regions: Northeast—CT , ME, MA, NJ, NY, PA, RI, and VT; Midwest—IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, and WI; South—AR, DE, DC, FL, KY, LA, MD, NC, OK, SC, TN, TX, and VA; and West—AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, and WY.
⁶ See Chapter 2—Definitions, Terms, and Classification Systems for Co-Occurring Disorders—in the following resource: Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders (Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration

Suggested Citation

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (April 22, 2010). The TEDS Report: Puerto Rican Admissions to Substance Abuse Treatment. Rockville, MD.