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Drug and Alcohol Dependence 84S (2006) S76–S84

Improving drug treatment services for hispanics: Research gaps andscientific opportunities

Margarita Alegrıa a,∗, J. Bryan Page b, Helena Hansen c, Ana Mari Cauce d, Rafaela Robles e,Carlos Blanco f, Dharma E. Cortes g, Hortensia Amaro h, Armando Morales i, Paige Berry j

a Department of Psychiatry, Center for Multicultural Mental Health Research, 120 Beacon St., 4th Floor,Cambridge Health Alliance, Harvard Medical School, Somerville, MA 02143, USAb Department of Anthropology, University of Miami, Coral Gables, FL 33124, USA

c Department of Psychiatry, New York University, New York, NY 10016, USAd Department of Psychology, University of Washington, Seattle, WA 98125, USA

e Center for Addiction Studies, Universidad Central del Caribe-Bayamon, Universidad Central del Caribe/CEA, Bayamon, PR 00960, USAf New York State Psychiatric Institute, Columbia University, New York, NY 10032, USA

g Cambridge Health Alliance, Department of Psychiatry, Harvard Medical School, Cambridge, MA 02139, USAh Institute on Urban Health Research, Bouve College of Health Sciences, Northeastern University, Boston, MA 02115, USA

i Neuropsychiatric Institute and Hospital, University of California-Los Angeles, Los Angeles, CA 90095, USAj New York State Department of Health, Albany, NY 12204, USA

bstract

Delivery of services to Hispanic drug users remains a great challenge, as shown by low service access and retention, and disproportionateegative consequences of drug abuse in the Hispanic population. This paper provides a critical analysis of current services research on Hispanicsith drug abuse problems, identifies gaps in the knowledge, and offers recommendations for scientific opportunities to address these gaps, focusingn four central needs: (1) the need to understand the circumstances of Hispanics in their own communities (i.e., community context); (2) the needo develop and test service delivery models tailored to Hispanics’ circumstances and special needs; (3) the need to remove client, provider, and

ystem barriers to utilization; and (4) the need to establish links between drug abuse services, social services, and other service sectors to optimizereatment outcomes. The authors suggest an approach that begins with a focus on the local Hispanic community and builds understanding of theultural context, inclusion of indigenous resources, recognition of barriers to enrollment and retention, and coordination of related services.

2006 Elsevier Ireland Ltd. All rights reserved.

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eywords: Hispanics; Services; Treatment; Outcomes; Ethnicity

. Introduction

Despite the rapid expansion of research on services over theast decade, the challenges in understanding the service needsf Hispanic drug users have never been greater. The delivery ofervices to Hispanic drug users often depends on service mod-ls and information that have succeeded with white males buto not necessarily meet the needs and circumstances of His-anics. Few behavioral intervention and treatments have been

pecifically developed for ethnic minority populations (Lopeznd Guarnaccia, 2000). As a consequence, there is insufficientmpirical research to inform service providers of the appropriate

∗ Corresponding author. Tel.: +1 617 503 8447; fax: +1 617 503 8430.E-mail address: malegria@charesearch.org (M. Alegrıa).

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376-8716/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.drugalcdep.2006.05.009

ssues to target in drug treatment service for Hispanic popu-ations, particularly with regards to treatment outcome studiesMiranda et al., 2003). Manifestations of this mismatch betweenpproach and population include low service utilization (Vegat al., 1999; Alegrıa et al., 2004) and retention levels (Ruiz andangrod, 1997), the absence of effective strategies to dimin-

sh barriers to service delivery (Jayakody et al., 2000), andisproportionate negative consequences for minorities sufferingrom drug abuse disorders (Buka, 2002). For example, Hispanicsnjection drug users were found to be less likely than whites tose residential treatments, and more likely to only access detox-fication services and to discontinue drug treatments (Lundgren

t al., 2001).

In assessing perceived need for alcohol- and drug-abuse orental health services, Wells et al. (2001) found the proportions

f those reporting need for services relatively equal among His-

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anic and non-Hispanic white respondents. However, amongll respondents perceiving need, Hispanics were more likely toeport not receiving the necessary services (26.5% of Hispanicsompared with 12.5% of whites), more likely to report delaysn care (22.7% versus 10.7%), less likely to be receiving activereatment (22.4% versus 37.6%), and tended to be less satisfiedith their drug abuse care than white respondents.In contrast, the National Household Survey of Drug Abuse

NHSDA) (SAMHSA, 2001) found a greater percentage of His-anics in the US (3.3%) reporting the need for treatment for anllicit drug problem than did whites (2.6%). The most commonddictions treated in Hispanic service admissions were alcohol36%), opiates (32%), and marijuana (14%; Drug and Alcoholervices Information System Report (DASIS), 2002).

The reviewed statistics also illustrate differences in treatmentccess by Hispanic subgroup and region of residence. Mexicanmericans comprise 58% of the total U.S. Hispanic popula-

ion but only 42% of Hispanic admissions in the Treatmentpisode Data Set (TEDS). Puerto Ricans comprise 10% of the

otal U.S. Hispanic population but account for 35% of all His-anic admissions. This profile suggests dramatic differences ineed and service delivery within Hispanic sub-populations. It islso helpful to define Hispanic communities in different partsf the United States. For example, the states with the largestercentages of Mexican American admissions for drug abuseervices are California (49%) and Colorado (14%); for Puertoicans, they are New York (44%), Connecticut (14%), and Mas-

achusetts (13%); and for Cubans they are Florida (48%) andew York (13%) (SAMHSA, 2002; DASIS, 2002).The purpose of this paper is to provide a critical analy-

is of current services research on Hispanics with drug abuseroblems, to identify the gaps in that knowledge, and to offerecommendations for scientific opportunities to address theseaps. We focus on four central needs: (1) the need to understandhe circumstances of Hispanics in their own communities (i.e.,ommunity context); (2) the need to develop and test serviceelivery models tailored to demonstrated needs/circumstances;3) the need to remove barriers to utilization; and (4) the need tostablish links between drug abuse services, social services, andther service sectors to optimize treatment outcomes. A generalssessment of the available literature was conducted, includinglectronic database searches and perusal of references cited byey articles to identify and select relevant literature. The prior-ty areas were selected on the basis of two criteria: the judgmentf an Expert Panel reviewing the literature and those areas thatere of specific relevance to Hispanic populations. As such,

his review is not exhaustive of all the available literature onervices research on Hispanics with drug abuse problems anday exclude priorities, such as treatment financing, that are of

xtreme importance for all populations.

. Priority area 1: understanding the communityontext

There is strong evidence that community context is a cen-ral determinant of health (Altman, 1995; Williams and Collins,001) and service outcomes (Gulzar, 1999). Several investiga-

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ors (Rhodes et al., 1999, 2005) have highlighted the importancef “risk environments” for increasing the diffusion of substancese behaviors. Others emphasize understanding the communityontext as a way to gain knowledge of acceptable treatmentptions within that community (Altman, 1995).

One community determinant of increased substance risk isloseness to major trade routes that facilitate population move-ent and mixing (Rhodes et al., 2005). Another identified com-unity factor is communities with socially and economically

ulnerable populations were there is social disintegration ofocial networks and inequitable distribution of services and insti-utional supports (Rhodes et al., 1999). However, the variousispanic communities in large U.S. cities do not necessarilyffer easily identifiable units amenable to labels (e.g., the His-anic community), nor are categorized by social disintegrationr inequitable distribution of resources. Additionally, each major.S. city has its own type of Hispanic community (e.g., Eastos Angeles has a strong identification as Mexican American

erritory, whereas New York’s Puerto Ricans and Dominicansccupy several different areas from the lower East Side to theronx). It is important to use multi-methods needs assessmentsnd community case studies to identify community factors asso-iated with both increased risk for substance disorders andeduced acceptability of drug treatment options. Identification ofopulations with whom Hispanics socially integrate (followinghe model of risk environments) and other relevant features ofommunity interaction could be evaluated. Assessments of theerspectives of local communities on drug abuse services andvailable treatment options and mapping community resourcesnd receptivity within available service programs should alsoe included. For example, the location of treatment facilitiesould be mapped onto zones of Hispanic habitation. Informa-ion could also be recorded on the treatment centers’ capabilitiesor addressing Hispanics’ culturally defined problems and issuese.g., availability of bilingual/bicultural staff). Each contextualetting would present a different set of significant communityarameters. In one setting, spatial distribution, Hispanic ethnic-ty, and action groupings may be the most significant features,hereas in another, networking, political alliances, and cultural

picenters may be salient features.

.1. Critical review and observations

Contextual community factors frequently cited in the liter-ture as linked to the increased risk for substance abuse areommunity unemployment, residential segregation, and proxim-ty to centers of drug trade as central (Bourgois, 1995; Williams,989; Singer, 1998; Alegrıa et al., 2004). A comprehensiveeview by Wallace (1999) showed how racial and ethnic dis-arities in alcohol and other drug patterns were a consequencef contextual-level risk factors that augment the risk of minori-ies using alcohol and drugs. Jones-Webb et al. (1997) foundhat Hispanic men had a four-fold risk of living in poor neigh-

orhoods compared with white men. Another study showed howhese poor communities were characterized by higher unemploy-

ent, higher population density, and a greater number of retaillcohol outlets, increasing the risk of alcohol-related problems

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Singer and Toledo, 1994). Therefore, studies using Hispanics a conceptual category should consider ways in which theseommunity factors may explain their findings independently of,r as mediated by, ethnicity.

.2. Recommendations

Undertake more community research studies that assess theommunity context, the community’s perspective on drug abusereatment and service delivery models as well as social andconomic factors impacting those community contexts wereispanics live. We recommend expanding research to:

Characterize the local Hispanic community in terms of struc-ture, cultural composition, and relations with the larger non-Hispanic community. These research studies could considerthe role of community unemployment, residential segrega-tion, proximity to centers of drug trade, and numbers of retailalcohol outlets in communities were Hispanics live as risk fac-tors. Investigators would use these characterizations to maptheir approaches to studying delivery of services and/or inter-vening to improve services as well as community factors thatmight prevent or promote use of alcohol or drugs. Communityresearch partnerships can help elucidate how services need tobe adapted for a particular community group or segment (e.g.,Hispanic gang-involved youth, outreach) and identify howfeasible and acceptable are the planned community interven-tions.Utilize a community participatory research framework:involve local community members and community-basedorganizations in community-based research. This researchinvolves capacity building in intervention, services researchfor community leaders; learning about community needs andstructure for researchers; and exploring the potential for alter-native, community-based models of care to enhance servicedelivery by addressing local needs.

. Priority area 2: service models for hispanic drugbusers

Community support, trust, and involvement appear criticalor tailoring drug abuse services to the needs of Hispanic com-unities. The mental health field has provided some examples

f the integration of service delivery into the context of His-anic communities, including Latino support groups and othernterventions that specifically incorporate ‘Hispanic-Americanultural values’ (Simoni and Perez, 1995; Lopez et al., 2002).ispanic professionals have developed approaches emphasizing

ollaboration with community-based organizations and otherelevant institutions within Hispanic communities to develop aocial action-oriented, multilevel approach to problems (Aranda,001). This approach views the community as an active devel-per of the intervention rather than a recipient of it. An advantage

o Hispanic community-based and community-action servicess that they can engage Hispanic clients, staff, and others inddressing the contextual factors of poverty and ethnic discrim-nation in which drug use can take place. In this way, they

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mplement institutional rather than strictly individual-level inter-entions to create livable communities for clients in recovery.

community-based collaborative model could take advantagef natural supports such as religious institutions in Hispanicommunities (Delgado, 1996) and small businesses (e.g., beautyarlors, bodegas; Delgado, 1997).

In addition to these service models, traditional inpatient, out-atient models of drug treatment, cognitive and other therapeuticodels, and family based approaches, need to be evaluated in

erms of outcomes with Hispanic drug abusers. The need to testamily psycho education programs for Hispanics is also essen-ial. Research identifying what treatment interventions best workor specific Hispanic subpopulations (e.g., gang involved youth,regnant mothers, low-literacy adults) is noted as a researchpportunity.

.1. Critical review and observations

The models described above have yet to be systematicallyvaluated in terms of effectiveness for Hispanic clients. Givenhanges in health policy such as managed care and the lim-ted allocation of resources to service the drug user populationHansen et al., 2004), the drug treatment field needs to testhe effectiveness of different treatment models (including pre-ention and case management) in achieving optimal recoveryutcomes for Latinos, particularly those with limited treatmenteadiness. Culturally appropriate explanatory models of His-anic drug use must take gender role differences into accountWarner et al., 2004). Chronic drinking among Hispanic mens seven-times higher than among Hispanic women (SAMHSA,998). Research on the protective aspects of normative valueystems from migrants’ countries of origin could be useful ineveloping culturally appropriate treatment services for immi-rants. However, there is an absence of research regarding com-unity reinforcements that might reduce the risk of substance

isorders. Caution in reinforcing such normative values is inrder, however, because value systems from countries of originay have both positive and negative influences on the well-being

f people who have emigrated. It is important to investigate theontextual factors behind normative values, both in communi-ies of origin and in migrant communities, so that they can besed to develop services that optimize the protective elementsf both an individual’s past and present cultural systems.

.2. Recommendations concerning service models

Much of the current research fails to develop meaningful cul-ural and contextual components such as places of origin (e.g.,uerto Rico, Mexico, Central America, etc.) that might explainpecific service needs or increased risk for drug abuse. Thoseew studies that thoroughly define cultural and contextual com-onents in drug abuse services provide useful models of how tolace services within specific Hispanic communities.

Our recommendation is to:

Test the effectiveness of community-based therapeuticapproaches that take advantage of natural supports (reli-

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gious organizations) and of those that bring evidence-basedtreatments to non-clinical environments (e.g., academic-community-partnerships).Evaluate and test collaborative research partnerships withHispanic community members that identify new and innova-tive approaches to drug abuse treatment services. For exam-ple, Roca, Inc., a community-based organization in Chelsea,Massachusetts, developed a community approach to drugtreatment that uses healing circles (i.e., a method of commu-nication and problem solving from the aboriginal and nativetraditions) for relationship development, healing, communitybuilding, and restorative justice efforts (Roca, 2005).Test community-level interventions that facilitate recoveryand reintegration of drug users within their Hispanic com-munities. Roca offers a bundle of services linked to recoveryand reintegration, including vocational, educational, and jobplacement services together with healing circles and contin-uous street outreach to monitor progress and develop strongrelationships with program leaders.

. Priority area 3: barriers to service utilization byispanic drug users

The current service models for Hispanic drug abusers do notddress the significant disparities in service delivery (Wells etl., 2001; Hansen et al., 2004; Lundgren et al., 2001). Attentiono barriers confronted by Hispanics and to needed cultural andontextual accommodations for service delivery is critical forffectiveness with Hispanic clients (Vega and Alegrıa, 2001).ith a well-defined concept of the Hispanic community set-

ing, investigators can focus on improving service delivery andddressing barriers to utilization. The drug treatment researcheld has focused more on the clinical basis of treatment rather

han on integrated care models that recognize that part of thereatment gap is programmatic barriers in accessing and stay-ng in care (Farabee et al., 1998; Hser et al., 1998). Some ofhese barriers are complicated admissions systems, poor rapportt intake, rigid scheduling, overbooked staff, and overburdenedreatment facilities (Festinger et al., 1995).

.1. Critical review and observations

Immigration has resulted in an increasing number of Spanish-peaking Hispanics in this country, but there are few Spanish-peaking providers (The Surgeon General’s Report on Mentalealth Care, U.S. DHHS, 1999). This is particularly important in

ight of the fact that certain pharmacological treatments, such asuprenorphine treatment, can be administered in primary careettings (SAMHSA, 2000). Although the potential to deliverrug abuse treatment in primary care settings represents a signif-cant advance, Hispanic drug abusers may not benefit to the sameegree as other groups due to the scarcity of Spanish-speakingrimary care providers. The lack of culturally and linguistically

ppropriate services has been a major barrier to use of drug abuseervices (Amaro and Aguilar, 1994; Woodward et al., 1992).

For those patients who have access to services, patient-rovider communication plays an important role in treatment

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dherence, follow-up visits, and satisfaction with servicesBetancourt et al., 1999). Adherence to treatment is a critical fac-or in maintaining drug users in treatment long enough (at least 1ear) for treatment to be effective (Simpson et al., 1997). Effec-ive communication is also of utmost importance as successfulreatment requires understanding and transfer of informationnto action; however, studies show that patients interviewedmmediately after concluding a meeting with their physiciansre able to identify correctly only about 50% of the importantnformation (Stamler et al., 1987).

Poor literacy skills account for many problems in patient-rovider communication, but only recently have practitionersnd researchers turned their attention to the relationships amongiteracy, communication, and health outcomes. Individuals seek-ng drug abuse services need to find out where the services areffered and learn how to navigate through the delivery sys-em to access services. After access to services, patients needo engage in effective communication with providers in face-o-face encounters. Providers need to obtain pertinent medi-al and drug abuse history and clients needs to master skillshat will allow them to provide pertinent history, consent toarticipate in a treatment program, keep appointments, andollow treatment regimes (Cooper and Roter, 2002). Givenhat drug abuse treatment programs rely heavily on writtenr oral information provided to clients for engagement, reten-ion, and treatment purposes, it is surprising that there has noteen much focus on the role of health literacy Foreign-bornispanics in treatment for drug abuse are likely to need sup-ort services such as native language-speaking staff or inter-reters who can help them interact with non-Spanish-speakingroviders.

Hispanic populations are adversely affected not only by liter-cy and linguistic barriers, but also by the acculturation processnd adaptation to a new environment, social and institutionalsolation, and poverty (Strug and Mason, 2001) that can presenterious obstacles to service utilization. In addition, the legal con-erns of undocumented immigrants are a barrier to accessingare (Ross, 1995). Furthermore, it is important to facilitate theevelopment of a cultural continuum between low-acculturatedispanic parents and their highly acculturated Hispanic ado-

escents for successful drug abuse treatment (Santisteban et al.,996; Szapocznik et al., 1988).

Research in community mental health settings has stressedhe importance of cultural expectations for treatment and theegree to which they match the characteristics of the serviceystem in understanding health care access and retention (Sue etl., 1991). These expectations extend to the language in whichhe clinical encounter takes place, the nature of the work-up andnterpretation of symptoms, the treatments offered, and the out-omes envisioned, the attitude toward including social-supportetworks in recovery (including spiritual communities), andhe way in which the perceived stigma of illness is addressedGuarnaccia and Rodrıguez, 1996; Rogler and Cortes, 1993).

nvestigators have repeatedly noted that traditional Hispanics areesponding to alternate cultural norms (e.g., lack of warmth in thelinical encounter) regarding these issues and that the mismatchetween their expectations and the mainstream health system

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esults in greater underutilization than among non-HispanicsU.S. DHHS, 2001).

Lack of health insurance is another barrier to drug abuse ser-ice delivery. More than a third (37%) of Hispanic Americans areninsured, a rate almost twice as high as that of whites (Brownt al., 2000). This low rate of insurance coverage among Hispan-cs appears to be a function of ethnicity, immigration status, anditizenship status. These barriers to Hispanics’ use of servicesffect retention.

Six major large-scale studies on retention of clients inrug abuse treatment have been conducted since the 1970s:he Drug Abuse Reporting Program (DARP), the Drug Treat-

ent Outcome Prospective Study (TOPS), the Drug Abusereatment Outcomes Studies (DATOS), the National Treat-ent Improvement Evaluation Study (NTIES), the Californiarug and Alcohol Treatment Assessment (CALDATA), and theervices Research Outreach Survey (SROS). In addition, theIDA Clinical Trials Network is currently conducting studiesf drug abuse treatment retention and outcomes. These stud-es differ in sampling size and approaches, geographic areas,ength of follow-up periods, demographic characteristics of par-icipants, modalities of treatment, and size of Hispanic sam-les. Of these studies, CALDATA and NTIES have the largestroportion of Hispanics in the study samples, although thisaries significantly by treatment modality. For example, in theALDATA study, Hispanics comprised 38% of methadone and3% of non-methadone outpatient study participants, whereashe proportion of Hispanic clients in SROS was much lowercross all modalities of treatment (between 3 and 13%). Spe-ific gaps in knowledge include the lack of studies on how tomprove communication between caregivers and Hispanic clien-ele for effective services; information on how specific programeatures, such as case-management approaches, may improveetention and completion of drug-abuse treatment among His-anics; studies that assess the impact of poor literacy skillsn retention, adherence, and completion of drug-abuse treat-ent among Hispanic clientele; data on the effects of immigra-

ion and cultural adaptation needs, including alternative culturalxpectations of drug abuse services on utilization and reten-ion, and information on how lack of insurance coverage influ-nces retention and completion of drug treatment services forispanics.

.2. Recommendations concerning barriers to servicetilization

Our recommendation is to develop research studies that willenerate information on system, provider and client level barri-rs to:

Test the effects of improved communication between care-

givers and Hispanic clientele and its impact on retention inpharmacologic and cognitive substance abuse treatments;Assess programs on Latino’s health literacy for entry andengagement in care and decision-making in substance abusetreatments;

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Evaluate the impact of insurance coverage on access to sub-stance abuse services, sustained attendance in drug treatmentsand relapse recovery;Test system interventions to redesign complicated admissionssystems, improve patient engagement at intake, accommodateflexible scheduling, and reduced provider burden.

. Priority area 4: hispanic drug users’ service linkagesith other service sectors

The characteristics of the Hispanic drug abuser, coupled withcomplex need profile, suggests the need for comprehensive

ervice delivery and a linkage with other service sectors.

.1. Critical review and observations

The literature on linkages between social or health servicegencies and drug abuse treatment is sparse. Studies of clientsf various ethnicities in public social service and health care sys-ems indicate that few social and health service clients who needrug abuse treatment receive referrals (Weisner and Schmidt,993, 1995); current state and federal government policies torivatize and reduce funding for public health and social ser-ices are likely to weaken the existing linkages. Since muchf the literature on best practices with regard to integration ofocial, health, and drug abuse services is not specific to His-anics, we extrapolate studies of the integration of health andocial services with drug treatment for the general population toispanics.Analysts of welfare reform call attention to drug abuse as an

mpediment to employment (Woolis et al., 2000; Jayakody etl., 2000; Fleming, 1997; Alcoholism and Drug Abuse Weekly,001). However, pilot projects integrating drug abuse treatmentith job placement show a positive relationship among employ-ent, participation in treatment, and reduced drug use (Wickizer

t al., 2000; Woolis et al., 2001). Stable housing is also posi-ively associated with successful drug abuse treatment (Suffet,999; Sullivan, 1992; Johnston and Rowe, 1995), and drug treat-ent programs located within public housing complexes have

emonstrated successful outcomes (Metsch et al., 2001). Yetederal law requires public housing programs to evict tenants ifmember of their household engages in any drug-related activ-

ty. Thus, exclusionary public housing policies may act as andditional barrier to treatment (Dilworth, 1997), despite the facthat an inclusive policy of housing-based treatment promises toncrease access to and effectiveness of treatment. Given that U.S.ispanics are an especially young population with a high birth

ate (Gutierrez et al., 2000), child and family services for His-anics in drug abuse treatment merit special attention (Hansent al., 2004). Drug abusers with children, especially women,tand to benefit greatly from treatment that is integrated withamily support services. Parents’ drug abuse puts children atisk for developmental problems, neglect, and abuse (Black et

l., 1994), while family responsibilities and fear of child abusend neglect charges often impede women from seeking treat-ent (Grella, 1996; Kane-Cavaiola and Rullo-Cooney, 1991).nhanced drug abuse treatment programs providing transporta-

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ion, outreach, and childcare and child treatment services haveetter outcomes than standard treatment, underscoring the util-ty of family services in optimizing treatment outcomes (Marsht al., 2000). However, the dual role of some public family ser-ice agencies as both service provider and punitive arm of lawnforcement presents a potential barrier to drug abuse treatmentor women. Yet child-welfare clients who are referred to treat-ent demonstrate successful treatment outcomes and a higher

ate of child custody retention (Semidei et al., 2001; Gregoirend Schultz, 2001). Women with children in treatment indicatehat their role as mother is a powerful motivator to completereatment and prevent relapse (Hardesty and Black, 1999).

Prison-based substance abuse treatment programs haveained substantial federal support in the last decade and haveeen shown to be effective (Pelissier et al., 2001; Simpson andexler, 1999), although studies of post-release populations indi-

ate that adequate community-based aftercare and related socialervices are necessary to prevent relapse (Hall et al., 2001;iller et al., 1999). Given that a disproportionate number of.S. inmates are Hispanic, and that the rate of incarceration ofispanics in the U.S. has risen since the 1990s, corrections-ased programs and drug courts that help connect offenders toommunity-based treatments merit special attention.

Another important linkage is with gang-prevention sectors.housands of young people (mostly males of low socioeconomictatus) are killed by gangs each year in the US; often the violences drug related, and Hispanics are involved in disproportion-te numbers (Center for the Study and Prevention of Violence,001). Health professionals in community clinics and hospitalsre often the first to interact with wounded gang members and arehereby well positioned to deliver interventions focused on drugreatment engagement and entry as well as violence prevention.he development of models for partnerships between hospitalsnd community-based service organizations can be particularlyaluable in identifying and engaging gang-affiliated Hispanicouth in family-based interventions to address drug abuse risknd problems in the target youth, siblings, and parents.

Since drug abusers are at elevated risk of chronic and dis-bling disease (e.g., HIV, other infectious diseases, as well asiver and heart disease) and Hispanic drug users are not likely toave access to regular health care, linkages between drug abusereatment and other health services are of vital importance. Stud-es that examined outcomes and costs of integrating medical carend drug treatment report that patients receiving integrated pri-ary care/drug treatment services had higher abstinence rates,

onger periods of abstinence, lower addiction severity scores,nd costs that were not significantly higher than those for patientsn groups receiving independent services (Friedmann et al.,003; Weisner et al., 2001). Little evidence exists to guide theeld as to how primary care might fit into an improved system ofare for patients with drug use disorders. Given the high rate ofsychiatric comorbidity among drug abusers (Virgo et al., 2001),ncluding Hispanics (Alegrıa et al., 1994; Amaro et al., 1999),

nd the fact that comorbid conditions may influence drug abusereatment outcomes (Ritsher et al., 2002), linkages between men-al health care and drug abuse treatment merit special attention.ther approaches to service integration include cross-training

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f social and health service providers in drug abuse counselingCockman, 2002) and centralized case management designedo coordinate client movement through judicial, drug treatment,nd social service systems (Terry et al., 2000).

It is necessary not only to evaluate the role of adding theseinkages to drug treatment services for Hispanics, but also to lookt the actual organizational and financing structure of care andts effects on fragmentation of drug abuse services for Hispanics.

anaged care companies have become increasingly involved inrug abuse treatment for the poor (and thus for Hispanics), asrivate behavioral health companies acquire government fundso provide drug abuse services for a capped fee (Lemak et al.,001; Alcoholism and Drug Abuse Weekly, 2001). The effectsf this shift on linkages between drug abuse treatment and healthnd social services have yet to be systematically examined.bservers point out that utilization of publicly funded alco-ol and drug abuse treatment went down after states contractedith managed care companies and suggest that managed care

estrictions impede the entry of publicly funded patients intorug treatment (McCarty et al., 2001), thereby weakening linksetween health services and drug abuse treatment. Managedare originally held the promise of more efficient linkage ofatients to drug treatment and ancillary services through exten-ive case management. However, in practice, case managementnder managed care differs from the model of case manage-ent advocated in the field of social work with managed care

rimary focus on cost-containment through utilization reviewather than on client assessments, appropriate referrals, or treat-ent monitoring (Hall et al., 2002). Keeping questions of service

ntegration and financing in mind while developing drug abusereatment systems forces us to see drug abuse as part of a spec-rum of related problems faced by Hispanics and helps us to

arshal the resources, strengths, and cultural practices of His-anic communities to support drug users in recovery.

.2. Recommendations concerning linkages to otherervice sectors

There are several gaps in our knowledge about service sys-em linkages relevant for Hispanic drug abusers. Few studiesystematically evaluate existing models of collaborative servicerovision within Hispanic communities or with Hispanic clien-ele. We recommend to:

Generate information that can be used to develop and test aworkable model of community-based delivery in Hispaniccommunities, including research that identifies untapped,informal Hispanic community-based resources.Develop and evaluate best practices that focus on the inte-gration of social, health and drug abuse services and that canoptimize treatment outcomes for Hispanic service users.

. Discussion

In summary, drug-abuse researchers can help develop broad-ased initiatives to improve drug-abuse services for Hispanicsy undertaking several topic areas in services research. These

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Los Angeles. Res. Social Work Practice 11 (2), 254–266.Betancourt, J.R., Carrillo, J.E., Green, A.R., 1999. Hypertension in multi-

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include research to identify key sociocultural (e.g., accultur-ation and cultural adaptation processes, health literacy, andclient-provider communication) and contextual (e.g., definitionof community, conditions, stressors) considerations that shouldbe taken into account to ensure success of services delivered toHispanic drug abusers. Also needed is research that developsand tests community-based models of service delivery for theHispanic drug abuser. Research on the nature of barriers thataffect Hispanic clientele regarding their enrollment in, retentionin, and completion of drug abuse treatment, as well as improvedoutcomes of care are also urgently desired. Other research oppor-tunities include the evaluation of novel approaches to servicesystem linkages using community-based organizations to pro-vide supports and services to drug-abusing Hispanics.

Hispanic clientele of drug abuse treatment services presentwith multiple and complex problems that need to be furtherinvestigated to provide guidance for the design and delivery ofservices. The current service delivery models may fall far short ofaddressing the needs of Hispanics. We suggest an approach thatbegins with a focus on the local Hispanic community and buildsunderstanding of the cultural context, inclusion of indigenousresources, recognition of barriers to enrollment and retention,and coordination of related services. This approach recommendsthat would-be caregivers and researchers define the communityrigorously and involve that community’s representatives in theformulation of approaches to solving problems of enrollmentand retention in care, thus making it most likely to meet theneeds of Hispanic drug abuse treatment clientele.

Acknowledgment

This research was supported by NIDA Grant R01 DA009438.

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