Consumer and gatekeeper motivation and behavior in a treatment system with constrained access: False-positive self-reporting at a Massachusetts detox facility

The intersection of clients seeking non-detoxification services, caring nursing practice and structural flaws in the Massachusetts substance abuse treatment system caused placement mismatches in 14.25% of 828 consecutive detoxification admissions. Why would people seek treatment for a serious substance use disorder that they did not have? Quantitative analysis found false-positive self-reporting by was strongly associated with six independent variables. Persons with a Blood Alcohol Concentration of .08% or lower were seven times more likely to be false-positive self-reporters. Cocaine users and those currently on probation or parole were three times more likely to have this treatment mismatch. Qualitative analysis determined that unlike some transactions involving “street-level bureaucrats” and persons seeking service, where gatekeepers tend to resist organization or direction by clients, the process of admitting people to a detoxification unit for a level of care that they did not need appeared to be collaborative rather than confrontational. Admitting nurses did not appear to be under any pressure to fill beds with mismatched clients. Clients were found to be acting rationally within an irrationally constructed treatment system. These results have implications for system capacity and access, professional training, and funding, planning and operation of substance abuse treatment systems. Knowledge about how consumers of health care act in an arena of constrained resources and health care reform can be informative of policy in areas beyond that of seeking detoxification services in Massachusetts.