Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis

Facilitators and barriers to collaboration between drug courts and community-based medication for opioid use disorder providers

INTRODUCTION

Access to medications for opioid use disorder (MOUD) is limited for individuals in drug courts - programs that leverage sanctions for mandatory substance use treatment. Drug courts rely on community agencies to provide MOUD. However, relationships with MOUD agencies, which impact access to treatment, are understudied. We examined barriers and facilitators from drug court staffs' perspectives to understand how to enhance collaborations with MOUD providers.

METHODS

Drug court staff (n = 21) from seven courts participated in semi-structured interviews about their experience in collaborating with MOUD providers. Interviews were informed by the Consolidated Framework for Implementation Research. Inductive (theory-based) and deductive (ground-up) approaches were used for analyses.

RESULTS

Facilitator and barrier themes centered around the needs and resources of drug court participants, external policies such MOUD access in jails, networking with external agencies, and beliefs about MOUD providers. Drug court staff preferred working with agencies that offered MOUD alongside comprehensive services. Drug courts benefited when jails offered MOUD in-house and facilitated community referrals. Existing relationships with providers and responsive communication eased referrals and served to educate the courts about MOUD. Barriers included logistical limitations (limited hours, few methadone providers) and inadequate communication patterns between providers and drug court staff. A lack of confidence in providers' prescribing practices and concerns around perceived overmedication of participants impacted referrals, interagency collaboration, and further burdened the participants.

CONCLUSIONS

Collaboration between drug courts and MOUD providers was driven by patient needs, external policies, communication patterns, and perceptions. Interventions to increase access MOUD for drug court participants will need to incorporate collaboration strategies while considering the unique features of drug courts.

Prediction of anorectal malformations with bladder-neck/urethral-prostatic fistula using classification and regression tree analysis

BACKGROUND

The anorectal malformations (ARMs) with bladder-neck/urethral-prostatic fistula in males are the most complex groups in ARMs. It is essential to diagnose them effectively before the primary operation for both surgical modalities and future functional prognosis can be quite different from other types. Our study aimed to develop a classification and regression tree (CART) model for the prediction of ARMs with bladder-neck/urethral-prostatic fistula.

METHODS

A total of 132 newborns with ARMs were included retrospectively and randomly assigned to the training sample and test sample in a 3:1 ratio. The pouch-perineum distance of ultrasound (PPDU), the pouch-perineum distance of invertogram (PPDI), and the rectum gas above the coccyx (RGAC) on the invertogram were hypothesized can serve as individual predictors. The CART analysis was used to determine the best combination of candidate predictors. The model's performance was assessed by the area under the receiver operating characteristic curve (AUC) and validated in the test sample.

RESULTS

All three individual predictors were included in the CART model to predict the ARMs with bladder-neck/urethral-prostatic fistula in the derivation cohort with the following test characteristics (95% CI): sensitivity 75.6% (60.1 to 86.6); specificity 88.9% (76.7 to 95.4); AUC 0.909 (0.854 to 0.965). The model's predicted accuracy was validated in the test cohort (AUC = 0.883). In all 132 subjects, the AUC of the tree model was significantly superior to that of the best individual index: PPDU (0.901 vs. 0.819; p = 0.005).

CONCLUSIONS

A predictive model that consists of PPDU, PPDI, and RGAC may be useful in predicting ARMs with bladder-neck/urethral-prostatic fistula.

Evaluating the implementation of a prisoner re-entry initiative for individuals with opioid use and mental health disorders: Application of the consolidated framework for implementation research in a cross-system initiative

Given the interrelated nature of opioid use, criminal justice interaction, and mental health issues, the current opioid crisis has created an urgent need for treatment, including medication assisted treatment, among justice-involved populations. Implementation research plays an important role in improving systems of care and integration of evidence-based practices within and outside of criminal justice institutions. The current study is a formative qualitative evaluation of the implementation of a cross-system (corrections and community-based) opioid use treatment initiative supported by Opioid State Targeted Response (STR) funding. The purpose of the study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) to a cross-system initiative, and to identify key barriers and facilitators to implementation. The process evaluation showed that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent and structured forums for cross-system communication. Challenges related to recruitment and enrollment, staffing, MAT, and data collection were addressed through the collaborative development and continuous review of policies and procedures. This study found CFIR to be a useful framework for understanding implementation uptake and barriers. The framework was particularly valuable in reinforcing the use of implementation research as a means for continuous process improvement. CFIR is a comprehensive and flexible framework that may be adopted in future cross-system evaluations.

Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis

OBJECTIVES

To (i) identify predictors of outcome for the physiotherapy management of shoulder pain and (ii) enable clinicians to subgroup people into risk groups for persistent shoulder pain and disability.

METHODS

1030 people aged ≥18 years, referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited. 810 provided data at 6 months for 4 outcomes: Shoulder Pain and Disability Index (SPADI) (total score, pain subscale, disability subscale) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH). 34 potential prognostic factors were used in this analysis.

RESULTS

Four classification trees (prognostic pathways or decision trees) were created, one for each outcome. The most important predictor was baseline pain and/or disability: higher or lower baseline levels were associated with higher or lower levels at follow-up for all outcomes. One additional baseline factor split participants into four subgroups. For the SPADI trees, high pain self-efficacy reduced the likelihood of continued pain and disability. Notably, participants with low baseline pain but concomitant low pain self-efficacy had similar outcomes to patients with high baseline pain and high pain self-efficacy. Cut-off points for defining high and low pain self-efficacy differed according to baseline pain and disability. In the QuickDASH tree, the association between moderate baseline pain and disability with outcome was influenced by patient expectation: participants who expected to recover because of physiotherapy did better than those who expected no benefit.

CONCLUSIONS

Patient expectation and pain self-efficacy are associated with clinical outcome. These clinical elements should be included at the first assessment and a low pain self-efficacy response considered as a target for treatment intervention.

The Criminal Justice Experience of African American Cocaine Users in Arkansas

BACKGROUND

African Americans are incarcerated at rates much higher than other racial and ethnic groups in the United States.

OBJECTIVES

We sought to qualitatively explore the relationships between ongoing involvement in the criminal justice system and continued drug use in a population of urban and rural African American cocaine users in a southern state.

METHODS

Semi-structured qualitative interviews were conducted among African American cocaine users in Arkansas between 2010 and 2012. Participants resided in both rural (two counties located in the eastern Arkansas Mississippi delta region) and urban (the county including the capital city of Little Rock) areas.

RESULTS

Numerous important themes emerged from participants' narratives, including chronic involvement with the criminal justice system (being a "career criminal"), continued access to drugs while incarcerated, relapse, and reincarceration and lack of access to effective drug treatment. Conclusion/Importance: The themes which emerged from our data speak to the collective experience that many substance using populations in the United States face in dealing with the criminal justice system. Our findings highlight the need to better, more holistic ways of engaging African American substance users in community based substance use treatment and supportive services.

Sociodemographic characteristics of Turkish patients who violated a supervised probation program

We aimed to investigate sociodemographic characteristics of individuals under a supervised probation program used in Turkey and to compare characteristics of noncompliant versus no-need-to-treat individuals in order to determine the effect of sociodemographic characteristics on success of the supervised probation program. In total, 4,006 individuals who submitted to the supervised probation program of our hospital were evaluated retrospectively from patient data and follow-up records. The mean age of patients was 28.4 ± 8.0 years. We compared the sociodemographic characteristics of "no-need-to-treat" patients (n = 2,205) and "noncompliant" patients (n = 391). We found differences between sociodemographic characteristics of no need to treat and noncompliant groups. We conclude that age, education, presence of self-mutilation, starting age of smoking or substance use, and family history are important factors affecting treatment compliance and success. Therefore, more detailed programs for noncompliant patients should be developed to increase treatment performance.

Changes in Inmates' Substance Use and Dependence From Pre-Incarceration to One Year Post-Release

PURPOSE

To assess changes in inmates' misuse of substances from pre- to post-incarceration.

METHODS

In Study 1, professionals (n = 162) and laypersons (n = 50) predicted how jail inmates' substance misuse would change from pre-incarceration to post-release. In Study 2, a longitudinal study of 305 jail inmates, we examined actual changes in substance use and dependence from pre-incarceration to the first year post-incarceration, as well as whether changes varied as a function of demographic, criminal justice, treatment, and personality factors.

RESULTS

Professionals and laypersons predicted little change in substance misuse whereas, in fact, inmates' frequency of substance use and dependence decreased substantially from pre-incarceration to post-release. Sharper decreases were observed for inmates who were female, younger, more educated, serving longer sentences, enrolled in substance abuse treatment, high in shame-proneness, and low in criminogenic thinking. Race, first time incarceration, transfer to other correctional facilities, mandated community supervision (probation), and guilt-proneness did not predict changes in substance use or dependence.

CONCLUSIONS

Although substance misuse decreased, this remains a population high in need of substance abuse treatment both upon arrest and at one year post-incarceration; 60% of former inmates met at least one DSM-IV criterion for substance dependence at one year post-release.

The unmet medical needs of correctional populations in the United States

The goal of this study was to document the health needs of members in the criminal justice system and the capacity of the system to meet those needs. Using data from the National Criminal Justice Treatment Practices survey, we estimated the number of adults under correctional control who need medical care and the capacity of the correctional system to provide needed care. A mailed survey of 431 adult correctional agencies and administrators was used to define the capacity and techniques of the correctional system to meet the medical needs of the offender population. Most offenders in jail and prison received tuberculosis screening, physical health services, and mental health screening and treatment. Screening for sexually transmitted diseases (STDs) and provision of detoxification or methadone maintenance were universally absent, regardless of criminal justice setting. Community corrections settings were lacking in most health care areas. Prisons and jails are constitutionally mandated to provide health care; however, community corrections agencies are not federally required to provide health services. While community correction settings have the lowest provision of health care services, prisons and jails also demonstrate a deficiency in most services, but particularly for STD screening, substance abuse detoxification, and opioid maintenance therapies.

Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors

Background

Former inmates are at high risk for death from drug overdose, especially in the immediate post-release period. The purpose of the study is to understand the drug use experiences, perceptions of overdose risk, and experiences with overdose among former prisoners.

Methods

This qualitative study included former prison inmates (N = 29) who were recruited within two months after their release. Interviewers conducted in-person, semi-structured interviews which explored participants' experiences and perceptions. Transcripts were analyzed utilizing a team-based method of inductive analysis.

Results

The following themes emerged: 1) Relapse to drugs and alcohol occurred in a context of poor social support, medical co-morbidity and inadequate economic resources; 2) former inmates experienced ubiquitous exposure to drugs in their living environments; 3) intentional overdose was considered "a way out" given situational stressors, and accidental overdose was perceived as related to decreased tolerance; and 4) protective factors included structured drug treatment programs, spirituality/religion, community-based resources (including self-help groups), and family.

Conclusions

Former inmates return to environments that strongly trigger relapse to drug use and put them at risk for overdose. Interventions to prevent overdose after release from prison may benefit from including structured treatment with gradual transition to the community, enhanced protective factors, and reductions of environmental triggers to use drugs.

Understanding the importance of organizational and system variables on addiction treatment services within criminal justice settings

NIDA's Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) is the primary vehicle for testing emerging treatment interventions and fostering adoption of evidence-based therapies in criminal justice settings. The papers in this issue of Drug and Alcohol Dependence use data from the CJ-DATS National Criminal Justice Treatment Practice Survey to explore the influence of organizational and system variables on access to addiction treatment and the types of services available within correctional settings. This essay provides context for the papers in this issue of Drug and Alcohol Dependence. Systems and organizational interventions that improve the delivery and quality of drug abuse treatment services are described and the potential to apply systems change thinking to addiction treatment services available in the criminal justice system is discussed. Each paper is described briefly. CJ-DATS is evolving to support research at the organizational and systems level that facilitates the implementation and sustainability of research-supported treatments and business practices in criminal justice settings.

Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions

In recent years, there has been an increased examination of organizational-level innovation adoption in substance abuse treatment organizations. However, the majority of these studies have focused on community-based treatment centers. One understudied area of the substance abuse treatment system is correctional institutions. This study uses the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative's National Criminal Justice Treatment Practices (NCJTP) survey to examine the adoption of detoxification services and pharmacotherapies for the treatment of substance abuse across a nationally representative sample of correctional institutions (n=198). There were significant differences between jails and prisons in the percentage of organizations offering detoxification services and medications. Specifically, detoxification services were offered by 5% of prisons and 34% of jails; and, medications were offered by 6% of prisons and 32% of jails. Binary logistic regression models were used to examine the associations between these services and organizational characteristics, including context, resources, previously introduced practices, culture, and systems integration. Variables measuring organizational context and previously introduced practices were significant correlates of the provision of both detoxification services and medications. Multivariate results indicated that the differences between jails and prisons remained significant after controlling for other organizational factors. Although the adoption of detoxification services and pharmacotherapies may be a controversial topic for correctional institutions, these services have the potential to improve offender well-being and reduce public health risks associated with substance abuse.

Organizational context, systems change, and adopting treatment delivery systems in the criminal justice system

The correctional system does not include service provision as a primary goal, even though individuals in prison, jail, and on probation/parole have large unmet substance abuse treatment needs. In response to mandates in the U.S. Constitution for basic health care, services are provided for incarcerated offenders, but generally do not include substance abuse treatment. The system does little to extend any type of health care service to individuals in community settings. This leaves the majority of offenders (6 million under community supervision in the U.S.) basically unattended, even with substance abuse disorders that are four times greater than the general public. The challenge of adapting the correctional system to be part of an integrated service provision system - working in conjunction with the public and private community-based service delivery sector - has intrigued researchers and policy makers over the last two decades. A series of articles using data from the National Criminal Justice Treatment Practices survey have examined factors that influence the adoption of a myriad of substance abuse treatment services for offender populations in various settings. These articles explore the factors that affect adoption and implementation, and provide guidance on issues relevant to organizational change and a dual mission of correctional agencies to advance public safety and public health. This special issue of Drug and Alcohol Dependence is devoted to understanding organizational constructs and factors to improve health outcomes for offenders.