Abstract
BACKGROUND: Social determinants of health (SDOH) and clinical severity factors are known to shape substance use disorder (SUD) treatment outcomes, yet limited research has explored how these influences differ by sex. Understanding these differences is important to improving treatment equity and outcomes in publicly funded treatment systems. METHODS: This study analyzed data from the 2018-2022 Treatment Episode Data Set-Discharges (TEDS-D), a national dataset of adults discharged from publicly funded SUD treatment programs. Sex-stratified binary logistic regressions were used to examine predictors of two outcomes: treatment non-completion and substance use at discharge. Predictors included SDOH (i.e., employment, education level, housing status, criminal justice involvement, prior treatment history, marital status, health insurance coverage and treatment duration) and indicators of SUD severity (e.g., age at first use, polysubstance use, and co-occurring psychiatric disorders). RESULTS: Both SDOH and clinical severity indicators were significantly associated with poorer treatment outcomes, with distinct patterns by sex. Women showed more consistent risk for poor treatment outcomes across predictors, including unemployment, psychiatric comorbidities, and polysubstance use, while lack of prior treatment history was the strongest predictor of substance use at discharge and dropout for men. Other predictors, such as housing instability, criminal justice involvement, and later-onset substance use, were also associated with increased risk of non-abstinence and dropout, with notable sex differences. Health insurance coverage was associated with better outcomes for both sexes, with the protective effect more consistent in women. CONCLUSIONS: These findings emphasize the need for sex-informed treatment approaches that address both social determinants of health and clinical complexity. Tailoring care to the unique risks and contexts of men and women may improve retention and reduce substance use at discharge, particularly in publicly funded systems. Highlights We examined social determinants of health (SDOH), and substance use disorder (SUD) severity-related predictors of substance use and treatment completion in a national sample of approximately 7 million adults. Women demonstrated more consistent vulnerability across predictors, including unemployment, co-occurring psychiatric disorders, and polysubstance use. For men, lack of prior treatment for SUD was the most consistent predictor for substance use at discharge and treatment dropout. Housing instability, access to healthcare, and financial barriers showed sex-specific effects, with women generally experiencing great risk of unsuccessful treatment. Findings highlight the importance of improving SUD care to address sex-specific risks and structural barriers, especially in publicly funded systems. Plain English Summary Substance use treatment is not a one-size-fits-all process. Recovery is shaped by both structural challenges, such as housing instability or limited access to care, and the clinical severity of substance use. These factors influence whether someone completes treatment and stays abstinent, and they often affect men and women in different ways. In this study, we analyzed data from approximately 7 million publicly funded substance use treatment episodes across the United States. We looked at how social determinants of health (e.g. employment status, education, housing, access to treatment) and clinical factors (e.g. age of substance use onset, psychiatric comorbidities and polysubstance use), were associated with two key outcomes: whether a person completed treatment and whether they reported use of their primary substance at the end of care. We found that women often faced greater challenges, especially regarding unemployment, co-occurring mental health conditions and using more than one type of substance. For men, being new to treatment was a strong predictor of poorer treatment success. These findings demonstrate the need for treatment programs to offer support that meets men and women where they are, considering the different barriers and challenges each group may face along the path to sustained recovery.