Sex, Race, and Ethnicity as Intersectional Predictors of Outpatient Substance Use Disorder Treatment Attrition

Nicholas L Bormann,1 Tyler S Oesterle,1 Mark A Lifson,2 Doo-Sup Choi,1,3 Stephan Arndt4,5 1Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA; 2Center for Digital Health, Mayo Clinic, Rochester, MN, USA; 3Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA; 4Department of Psychiatry, University of Iowa, Iowa City, IA, USA; 5Department of Biostatistics, University of Iowa, Iowa City, IA, USACorrespondence: Nicholas L Bormann, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA, Email [email protected]: An intersectionally-informed approach considers how personal factors such as sex, race, and ethnicity may compound to impact individuals and their health outcomes. We examined how these factors interact to influence treatment attrition in an outpatient, treatment-seeking substance use disorder population.Patients and Methods: The Treatment Episode Dataset-Discharges (2017– 2021) provided de-identified data, with each outpatient treatment encounter assessed at admission and discharge, yielding a repeated cross-sectional design. The repeated admission bias was defined as the odds of total admissions relative to the odds of the first admission for each group. Discharge reasons of dropped out or terminated were coded as treatment attrition. Logistic regression assessed treatment attrition, with the interaction term assessing nonadditivity. The unadjusted model included sex, race and ethnicity, and their interaction term, and the adjusted model incorporated the state, primary substance, and age group.Results: Of 3,934,962 admissions, 1,668,338 (42.4%) were first admissions. White males were over-represented in repeat admissions, and Latina females were 22% less likely to be readmitted. For first episode encounters, females had significantly greater treatment attrition across all groups. Sex, race, and ethnicity, and their interaction were significant in both unadjusted and adjusted models. In adjusted models, the sex difference in attrition was 1.3 percentage points for White individuals (95% CI: 1.2– 1.5), but more than twice as large for Black (2.8; 95% CI: 2.5– 3.2) and Latino individuals (2.8; 95% CI: 2.4– 3.2).Conclusion: Our findings show that intersecting identities of sex, race, and ethnicity shape disparities in treatment engagement. Black and Latina females face compounded barriers to retention and re-engagement. Incorporating an intersectional perspective into addiction treatment planning and policy may help reduce attrition and improve equity in care.Keywords: addiction, bias, disparity, inequity, attrition, encounter, TEDS