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 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.

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 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 cluster sampling design within the facilities where I sample people within

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

administrators. The goal is to sample at least one worker in each category, as is available in each

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?”

Recruitment

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

(which most facilities have), and in the case I cannot find one I will search via LinkedIn or call

the facility. 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 facility and staff members at a facility asking
them to take my survey. If I do not get a response at this point, I will make phone contact with

the facility to reach the respondents. 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 non-

responders could be stratified, 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.