** Just so you know, I’m not planning on implementing this as part of my dissertation at the

current time/ I’m going to stick with doing 3 simple quant pieces looking at the medicalization of
addiction. That being said, I still think it fits well with my interests. While this is something I’d
LOVE to do in the future, given the current time/finance/etc. constraints of grad school, I don’t
think I’m actually going to be able to do it. So that being said, I don’t need as much feedback**

My dissertation addresses two general questions: why do institutions expand into other

institutional domains? And what are the impacts of institutional expansion? Through examining

the evolution of drug policy related to opioid misuse, I will attempt to disentangle how

expansions of institutional loci of control interact with definitional changes of who is a drug user.

In conjunction, I aim to unpack the institutional conflicts created by the gradual transition from

criminal justice institutions to health care institutions as the primary actors for tackling drug

misuse – highlighting the ways in which this expansion reproduces inequality, yet

simultaneously redefines how we think about institutional control.

There are three pieces to understanding how the US addresses opioid misuse: laws governing the

use and misuse of opioids, the institutions that address the social consequences of opioid abuse,

and the process of implementing and enforcing laws through these institutions. This chapter

looks at the role of substance abuse facilities in the chain of institutions that address opioid

misuse. Previously, if an individual were abusing opioid drugs they would be arrested and put

into jail – with very few (mostly white and wealthy individuals) getting access to drug treatment.

In the cases where drug treatment was accessible for marginalized populations, there was a

substantial distrust for these institutions and/or care was not tailored towards the needs of these

populations. With the expansion of drug treatment as the primary mechanism for addressing drug

offenses, there is a need to examine whether this expansion continues to reproduce the same

racial and class based disparities. Are improvements to addressing drug misuse only in relation
to the new group of individuals classified as opioid misusers, or has the medicalization of drug

misuse improved outcomes for all groups? Dually, how have changes in policy impacted the

practices of these institutions – have these medical institutions become liberalized sites of legal

knowledge dissemination (especially in the case of fatal overdose prevention laws and

propositions reclassifying drug offenses) or are they a new body of social control, disguised as a

scientized/medicalized body? Or have changes in policy simply given these institutions greater

license to employ and more widely disseminate a variety of treatment options, especially

medication assisted treatment options?

While the Substance Abuse and Mental Health Facilities survey provides some

information about rehabilitation centers it is limited in its ability to address these questions. It

contains some questions that get at gender and race specific treatment options, but they do not

identify specific practices facilities use to tailor these services to specific groups. Most

importantly, there is limited to no information on how these facilities interact with law

enforcement, one another, or the type of education disseminated in their programs. Another

weakness is that one member of the organization fills out this survey. Given that there are

different actors in these facilities from doctors to social workers to administrative staff, it is

important to understand how different actors in the same institution view and practice their work.

Consequently, I am proposing a multi-actor facility-based survey in Los Angeles county to

understand 1) institution’s awareness of new (relevant) policy, how they perceive policies, and

how policy impacts actors and their practices, 2) whether these actors see an interaction between

suitable treatment options and the population served, and 3) the extent to which law enforcement

and other organizations interact with a facility.

Sample
 The target population of this study is the 46 rehabilitation centers in Los Angeles County

with a certified Opioid Treatment Program, as identified by the SAMSHA Treatment Locator. I

will sample this target population at 100%. Even if the same company owns multiple facilities, I

will administer the survey to each individual facility as long as the staff is different. Including

the entire population of rehabilitation centers should ensure that when taking into account

nonresponse that I would still have a sufficient sample size. To increase the likelihood that

facilities want to take my survey, I would like to reach out to some county agencies (such as the

Department of Public Health and the Steering Committee Office of Diversion and Re-Entry) to

see whether they’d be willing to partner with me (in addition to my affiliation with UCI). This

would not only make my survey more credible, but also provide the county of Los Angeles an

opportunity to assess local rehabilitation resources and their integration into the larger

community.

I will use a stratified sampling design within the facilities where I sample people within

based on their position; specifically three categories of workers: doctors, social workers, and

administrators. Given that the size of treatment facilities varies greatly, I aim to sample at 50%

for each category of workers. While this strategy is not perfect, one of the benefits of it is that

bigger facilities (aka facilities who have more opportunities to have contact with patients), will

be represented proportional to their size – with the exception of rates of non-participation. Given

that the seniority of these staff will vary, I plan for the sample within each category to also be

stratified – with 50% of those surveyed in a category being senior staff and 50% being newer

staff. This allows us to further assess differences within treatment facilities – seeing whether or

not responses vary by seniority of staff. If this is not possible, for example if everyone has been

there for a long time/everyone is new, I will still use this sampling frame but note that there is
not much variation in the time an individual has been with the facility. While all individuals will

be asked general questions about their approach to drug treatment, questions will be specialized

for individuals based on their job description. For example, all individuals will be given

scenarios about a hypothetical patient and then asked what they would recommend. But, the

recommendations would be tailored based on their position i.e. the doctor is asked if they’d

recommend medication assisted treatment while the social worker is asked which community

based resources they think would be most helpful. Not all questions will be stratified in this way,

some questions will be asked to all individuals such as “What is your treatment philosophy?” or

“Are you familiar with Naloxone access laws?”, with the option of “I do not have a treatment

philosophy” included for those who may be sampled but not directly involved in patient

recovery.

Description of Survey Instrument

This survey addresses a few key topics of interest: treatment provider’s views about drug

treatment and its efficacy, treatment provider’s knowledge of new harm reduction policies,

services provided by treatment providers, strategies used by different actors in the facility to

address role specific issues that arise during drug treatment, and facility demographic

information (the information not reported in the SAMSHA Mental Health and Drug Treatment

Facility survey). This survey has two parts to it; Part A and Part B, C, and D. All staff members

will fill out part A, but after completing this section they will be directed to Part B, C, or D

depending on their roles. Part A asks staff about their role in the facility, how long they have

worked for the facility and in drug treatment, their ‘treatment philosophy’, and their knowledge

of new harm reduction policies including Good Samaritan 911 laws, Naloxone laws,

Propositions 47 & 64, and the Sobering Center in Skid Row. Part B is designed for doctors. It
asks more specifically about their experiences prescribing and monitoring individuals using

Medication Assisted Treatment, in addition to asking about what they define as a successful

treatment outcome (as this can vary between providers, some expect total abstinence from all

mind-altering substances, while others are okay with some alcohol/marijuana use). Part C is

designed for social workers. This section asks more about provider’s experiences and struggles

with the social part of recovery, in addition to asking about the extent to which law enforcement

interact with the facility. Part D is designed for administrative staff. The purpose of this section

is to get access to demographic information that was not asked about in the SAMSHA survey.

Recruitment

For each rehabilitation facility, I will first locate a list of their staff members on their website

(which most facilities have) to get an idea of facility size and get contact information for the

facility director. While the survey will be web based on Qualtrix, I plan to recruit facilities

through a tiered approach. I will first attempt to email the director of the facility to get

permission to survey the facility and staff members. This approach should also allow me to get e-

mail addresses/contact information for staff members. If I do not get a response at this point, I

will make phone contact with the facility to reach the director. If this is also unsuccessful or if

asked by the representative I contact at the rehabilitation facility, I will go to the facility in

person. I am concerned that there could be non-response bias, but I am unsure of in what

direction this would be; would facilities that primarily serve low-income individuals or that serve

primarily high income individuals be less likely to respond? Either way, I plan to assess whether

non respondents are stratified based on demographic or facility characteristics based on the

information provided about them in the SAMSHA treatment locator, which includes payment

accepted, types of treatment offered, etc.

Implementation

I plan to pilot test this survey instrument on partners of the Drug Policy Alliance, Tarzana

Treatment Centers given that we already have professional connections with them, which would

make getting access to them easier. They have multiple sites but I plan to test it at 3 of them

before revising and expanding to the entire sample. The survey will be programmed in Qualtrix

with the skip patterns programmed into the survey. To avoid asking too much of respondents, the

facility information that was not asked about in this survey will be matched with/gathered from

the SAMSHA Drug Treatment database and the N-SSATS survey. I aim to collect this data over

a period of 6 months and with the assistance of 3 other research assistants. I will train everyone

beforehand on the process of going about recruiting facilities.

APPENDIX A: Survey Instrument

Dear Facility Director,

The Community Health Partnership, consisting of the University of California-Irvine, the Drug
Policy Alliance, and the LA County [insert govt. agency partner here], needs your participation
in LA County Medication Assisted Treatment provider’s survey. Our goal is to understand the
drug rehabilitation services in LA County to better help connect individuals to drug treatment.
This survey also attempts to understand how well the county is doing at communicating to
service providers new harm reduction policies.

The Community Health Partnership is also creating a guide to Certified Opiate Treatment
Programs in LA County. With your permission we will include your facility contact information
as a thank you for participating. All responses to this survey, with the exception of your public
contact information, will remain confidential.

Thank you,

[Signature here]

Alexandra Olsen
Principal Investigator, University of California-Irvine Department of Sociology
Part A

1. What is your role at [TREATMENT CENTER NAME]?

o Doctor/Psychiatrist  ASK Part B after Part A
o Social Worker/Community Liaison  ASK Part C after Part A
o Counselor/Psychologist  ASK Part D after Part A
o Administrative Staff  ASK Part E after Part A

2. How long have you worked in drug rehabilitiation?

___ Years __ Months

3. How long have you worked at [TREATMENT CENTER NAME]?

____ Years ___ Months

4. Which of the following kinds of Medication Assisted Treatment do you offer/prescribe at

[TREATMENT CENTER NAME]?
Check all that apply
[] Buprenorphine/Suboxone
[] Subutex
[] Methadone
[] Vivitrol/Naltrexone
[] We do not prescribe Medication Assisted Treatment
[] Don’t Know

5. Do you have a personal treatment philosophy, i.e. a specific approach/ideas around to how you
treat drug addiction, for example “abstinence only is the only kind of treatment that works”, “for
people to change they need community support”, “medication assisted treatment is crucial to
successful treatment outcomes” or “treatment must be tailored to an individual’s unique needs”?
o Yes  GO TO Q5
o No  GO TO Q6
o Don’t Know  GO TO Q6

6. What is your personal treatment philosophy?

__________________________

7. Are you familiar with Naloxone access laws?

o Yes  GO TO Q8
o No  GO TO Q9
o Don’t know  GO TO Q9

8. On a scale of 1 to 5, how familiar would you say you are with Naloxone access laws?

1 2 3 4 5
(Have heard about this law in passing) (I have a general understanding) (I’m an expert on
these laws)
9. Have you received training on Naloxone access?
o Yes
o No
o Don’t know

10. Are you familiar with the Good Samaritan 911 Law?
o Yes  GO TO Q11
o No  GO TO Q12
o Don’t know  GO TO Q12

11. On a scale of 1 to 5, how familiar would you say you are with Good Samaritan 911 laws?

1 2 3 4 5
(Have heard about this law in passing) (I have a general understanding) (I’m an expert on
these laws)

12. Have you received training on Good Samaritan 911 Laws?

o Yes
o No
o Don’t know

13. Are you familiar with Proposition 47?

o Yes  GO TO Q14
o No  GO TO Q15
o Don’t know  GO TO Q15

14. On a scale of 1 to 5, how familiar would you say you are with Proposition 47?

1 2 3 4 5
(Have heard about this law in passing) (I have a general understanding) (I’m an expert on
these laws)

15. Have you received training on Proposition 47?

o Yes
o No
o Don’t know

16. Are you familiar with Proposition 64?

o Yes  GO TO Q17
o No  GO TO Q18
o Don’t know  GO TO Q18

17. On a scale of 1 to 5, how familiar would you say you are with Proposition 64?
1 2 3 4 5
(Have heard about this law in passing) (I have a general understanding) (I’m an expert on
these laws)

18. Have you received training on Proposition 64?

o Yes
o No
o Don’t know

19. Are you familiar with the Sobering Center on Skid Row?
o Yes
o No
o Don’t Know

GO TO PART B, C, D, or E

The following questions are specific to your role as a [INSERT ROLE HERE] at [INSERT
TREATMENT CENTER HERE]. This section should take no longer than 5-10 minutes to
complete, but is integral to understanding how we can improve policies and funding for drug
treatment in LA County

Part B – DOCTORS/PSYCHIATRIST ONLY

17. In your experience, what groups have issues gaining access/continually accessing Medication
Assisted Treatment? (Mark all that apply)
_ Young People (Under 25)
_ Middle Aged People (25-64)
_ Seniors (65+)
_ People with Health Insurance
_ People without Health Insurance
_ Homeless
_ Previously incarcerated individuals
_ Currently incarcerated individuals
_ Mentally ill/individuals with co-occurring mental health issues
_ Low income individuals
_ Wealthy individuals
_ LGBT individuals
_Chronically ill
_None of the above  GO TO Q19

18. You said that [INSERT MARKED CATEGORIES] make it difficult for some individuals to
access Medication Assisted Treatment? What do you think the most common reasons are for
this? (Mark all the apply)

REASO Financia They’re Too much Lack Legal Lack of High

N l not instability in of restrictions communit risk of
Reasons committe their lives family / y support fatal
d to (i.e. housing suppor Government OD if
treatment instability, t regulations relaps
job e
instability,
relationship
s unstable)
Cat1
Cat2
Cat3

CATEGORY CHECKED

19. In your experience, what groups respond best to Medication Assisted Treatment? (Mark all
that apply)
_ Young People (Under 25)
_ Middle Aged People (25-64)
_ Seniors (65+)
_ People with Health Insurance
_ People without Health Insurance
_ Homeless
_ Previously incarcerated individuals
_ Currently incarcerated individuals
_ Mentally ill/individuals with co-occurring mental health issues
_ Low income individuals
_ Wealthy individuals
_ LGBT individuals
_Chronically ill
_ None of the above GO TO Q21

20. Why do you believe that [INSERT CATEGORIES HERE] respond better to Medication
Assisted Treatment?

REASO Financi They’re Medicatio Greater Have Have Because Low

N al committe n access communit family there has risk to
Reasons d to Assisted to y support suppo been relaps
treatment Treatment doctors/ rt more e
s are a medical access to
best treatme Medicatio
practice nt n
Assisted
Treatment
Cat1
Cat2
Cat3
21. What would you define as a successful treatment outcome? Check all that apply
[] Patient is totally abstinent from all drugs/alcohol
[] Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will socially drink
[] Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will smoke marijuana
[]Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will use other drugs/alcohol occasionally
[] Patient uses Medication Assisted Treatment to abstain from drugs/alcohol
[] Patient successfully reintegrates back into their community/feels reconnected to positive
influences in their lives
[] Patient still uses their “drug of choice”, or the specific substance they were (most) addicted to,
but uses it in a safer way (i.e. uses clean needles, has stable housing, etc.)
[] Don’t know
[] Other _______________________

22. What do you think is the biggest barrier to patient success?

o Lack of job opportunities
o Lack of educational opportunities
o Lack of social/family support
o Patients are entering rehab when they are unwilling to change their behavior
o Patients are disillusioned with current treatment models
o Patients don’t believe that they’re worth helping
o Drug Treatment Programs are too expensive
o Drug Treatment Programs are not accessible
o Medication Assisted Treatment too expensive
o Medication Assisted Treatment is not accessible
o Don’t know
o Other ________________________

Part C - SOCIAL WORKER/COMMUNITY LIAISON ONLY

17. Do you serve populations that are currently under state supervision (i.e. on probation, parole,
diversion programs)
o Yes  GO TO Q18
o No  GO TO Q19

18. What percentage of your treatment population is under state supervision (i.e. on probation,
parole, diversion programs)?
o 0%-25%
o 25%-50%
o 50%-75%
o 75%-100%
19. In the past year, have you ever had to call the police to [TREATMENT FACILITY] for any
reason?
o Yes  GO TO Q20
o No  GO TO Q21

20. How many times have you called the police to [TREATMENT FACILITY] in the past
month? If you cannot remember, please provide an estimated range of the number of times
you’ve called the police
[NUMBER]

21. What reasons have you called/would you call police to the facility? (Check all that apply)
[] Patient violating parole/probation
[] Patient using drugs/alcohol at the facility
[] Patient stealing from other patient’s/the facility
[] Other __________
[] Will never/rarely call the police to the facility, unless there is an emergency (i.e. active
shooter)

22. On a scale of 1-5, how would you rate your interaction with law enforcement when they
normally come to your facility?
1 2 3 4 5
(Not helpful at all) (Somewhat helpful, somewhat unhelpful) (Very Helpful)

23. Do you provide post-treatment resources to your patients?

o Yes  GO TO Q24
o No  GO TO END

24. What post-treatment resources do you provide? Check all that apply
[] Connect patients with Sober Living Facilities
[] Post-release counseling
[] Referrals to outside Medication Assisted Treatment providers
[] Connecting patients with other community resources (i.e. AA or NA, support groups,
Therapeutic Communities)
[] Providing extra supplies of medication post-release (i.e. 3 months of an antidepressant, NOT
Medication-Assisted Treatment)
[] Educational Materials
[] Other ______________________________
[] Don’t know

25. What would you define as a successful treatment outcome?

[] Patient is totally abstinent from all drugs/alcohol
[] Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will socially drink
[] Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will smoke marijuana
[]Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will use other drugs/alcohol occasionally
[] Patient uses Medication Assisted Treatment to abstain from drugs/alcohol
[] Patient successfully reintegrates back into their community/feels reconnected to positive
influences in their lives
[] Patient still uses their “drug of choice”, or the specific substance they were (most) addicted to,
but uses it in a safer way (i.e. uses clean needles, has stable housing, etc.)
[] Don’t know
[] Other _______________________

25. What do you think is the biggest barrier to patient success?

o Lack of job opportunities
o Lack of educational opportunities
o Lack of social/family support
o Patients are entering rehab when they are unwilling to change their behavior
o Patients are disillusioned with current treatment models
o Patients don’t believe that they’re worth helping
o Drug Treatment Programs are too expensive
o Drug Treatment Programs are not accessible
o Medication Assisted Treatment too expensive
o Medication Assisted Treatment is not accessible
o Don’t know
o Other ________________________

Part D COUNSELOR/PSYCHOLOGIST ONLY

17. What issues do your patients most often struggle with, in addition to drug addiction? (Mark
the top 3)
_ Homelessness
_ Incarceration/Legal implications of past behaviors
_ Job Instability/Joblessness
_ Lack of family support
_ Lack of community support (i.e. church membership/community org membership)
_ Lack of skills/education
_History of Trauma/Abuse
_Mental illness/co-occurring mental health issues
_Chronic illness
_Physical issues
_Dental issues

18. What strategies do you use to address [ISSUE 1]?

[] Group Therapy
[] Individual Therapy
[] Cognitive Behavioral Therapy
[] Connecting patients to Social Services (i.e. getting them enrolled with food stamps/Medicaid)
[] Connecting patients with Legal Clinics
[] Getting patients enrolled in Trade School/GED courses/Community College
[] Holding workshops on different topics
[] Referrals to psychiatrists
[] Post-release support resources
[] Providing at least 3 months of medication post-release
[] Trauma informed therapy practices
[] Integrating family into treatment
[] Integrating community resources (such as NA or AA) into treatment
[] Other ____________________________
[] Don’t know

19. What strategies do you use to address [ISSUE 2]?

[] Group Therapy
[] Individual Therapy
[] Cognitive Behavioral Therapy
[] Connecting patients to Social Services (i.e. getting them enrolled with food stamps/Medicaid)
[] Connecting patients with Legal Clinics
[] Getting patients enrolled in Trade School/GED courses/Community College
[] Holding workshops on different topics
[] Referrals to psychiatrists
[] Post-release support resources
[] Providing at least 3 months of medication post-release
[] Trauma informed therapy practices
[] Integrating family into treatment
[] Integrating community resources (such as NA or AA) into treatment
[] Other ____________________________
[] Don’t know

20. What strategies do you use to address [ISSUE 3]?

[] Group Therapy
[] Individual Therapy
[] Cognitive Behavioral Therapy
[] Connecting patients to Social Services (i.e. getting them enrolled with food stamps/Medicaid)
[] Connecting patients with Legal Clinics
[] Getting patients enrolled in Trade School/GED courses/Community College
[] Holding workshops on different topics
[] Referrals to psychiatrists
[] Post-release support resources
[] Providing at least 3 months of medication post-release
[] Trauma informed therapy practices
[] Integrating family into treatment
[] Integrating community resources (such as NA or AA) into treatment
[] Other ____________________________
[] Don’t know
21. What would you define as a successful treatment outcome?
[] Patient is totally abstinent from all drugs/alcohol
[] Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will socially drink
[] Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will smoke marijuana
[]Patient no longer uses their “drug of choice”, or the specific substance they were (most)
addicted to, but still will use other drugs/alcohol occasionally
[] Patient uses Medication Assisted Treatment to abstain from drugs/alcohol
[] Patient successfully reintegrates back into their community/feels reconnected to positive
influences in their lives
[] Patient still uses their “drug of choice”, or the specific substance they were (most) addicted to,
but uses it in a safer way (i.e. uses clean needles, has stable housing, etc.)
[] Don’t know
[] Other _______________________

22. What do you think is the biggest barrier to patient success?

o Lack of job opportunities
o Lack of educational opportunities
o Lack of social/family support
o Patients are entering rehab when they are unwilling to change their behavior
o Patients are disillusioned with current treatment models
o Patients don’t believe that they’re worth helping
o Drug Treatment Programs are too expensive
o Drug Treatment Programs are not accessible
o Medication Assisted Treatment too expensive
o Medication Assisted Treatment is not accessible
o Don’t know
o Other ________________________

Part E ADMINISTRATOR ONLY

This part of the survey specifically asks about demographics of the treatment facility. It may be
helpful to compile this information before beginning this part of the survey.

17. How many patients did your treatment facility serve in the past year?
[NUMBER] patients

18. In the past year, what are the gender demographics of your treatment facility?
[NUMBER] Female patients
[NUMBER] Male patients
[NUMBER] Unknown
19. In the past year, what were the age demographics of your treatment facility?
[NUMBER] Under 18
[NUMBER] 18-25
[NUMBER] 26-34
[NUMBER] 35-64
[NUMBER] 65+
[NUMBER] Unknown

20. In the past year, what are the racial demographics of your treatment facility?
[NUMBER] White/Caucasian  GO TO Q22
[NUMBER] Hispanic/Latino  GO TO Q22
[NUMBER] Black  GO TO Q22
[NUMBER] Asian/Pacific Islander  GO TO Q22
[NUMBER] American Indian/Native American  GO TO Q22
[NUMBER] Other  GO TO Q22
[NUMBER] Unknown/Our facility does not track this data  GO TO Q21

21. While [INSERT TREATMENT FACILITY NAME] does not formally collect this data,
please estimate the racial demographics breakdown of your treatment facility
[PERCENTAGE] White/Caucasian
[PERCENTAGE] Hispanic/Latino
[PERCENTAGE] Black
[PERCENTAGE] Asian/Pacific Islander
[PERCENTAGE] American Indian/Native American
[PERCENTAGE] Other

22. What are the two most common types of payment used at your facility? (Rank 1, 2)
_ Out of pocket
_ Private Insurance
_ Medicaid
_ Govt. Insurance (i.e. VA benefits)
_ Free/All fees covered by a grant or facility funding
_ Other (explain)