Disseminating evidence-based practices in substance abuse treatment: a review with suggestions

FlourishCare Model of Integrated Care: The Validation of the Flourish Index-Revised

BACKGROUND AND OBJECTIVES

This study validates the Flourish Index-Revised (FI-R), a tool evaluating integrated healthcare models. The original Flourish Index (FI) was developed in 2018 and has been refined to align with the FlourishCare (FC) Model (Model) for geriatric primary care.

RESEARCH DESIGN AND METHODS

The Model provides integrated biopsychosocial healthcare to older adults. The FI-R uses 25 quality-of-care indicators and 7 contextual community indicators. The FI-R was validated with Categorial Principal Components Analysis (CATPCA) using a sample of 949 patients 50+ who were mostly female (73%), non-Hispanic White (70%), living in urban areas (90%), and married (29%), single (22%), or divorced (19%). The mean age was 73.46 (standard deviation [SD] = 10.86) and mean years of education was 14.30 (SD = 2.14).

RESULTS

CATPCA showed a 4-dimensional structure of biological, psychological, and 2 social determinants of health (SDOH) subdomains: health behaviors and community. Final selection of indicators was based on total variance accounted for >0.30, absolute values of item loadings >0.45, and not having cross-loadings >0.45 on 2 factors. Internal consistency (Cronbach's alpha) for the determinants were biological = 0.75, psychological = 0.76, SDOH:community = 0.70, SDOH:health behaviors = 0.50, and total FI-R = 0.95. Sensitivity to change was shown for the total FI-R, psychological determinants, and SDOH:health behaviors, but not for biological determinants.

DISCUSSION AND IMPLICATIONS

The validation of the FI-R shows promise for its usability to evaluate integrated healthcare models using existing measures in electronic health systems. More work is needed to improve the incorporation of SDOH:sociodemographics into the FI-R.

How do the Substance Abuse and Mental Health Services Administration's Technology Transfer Centers Decide What Evidence-Based Practices to Disseminate and Determine How to Do So? A Cross-Sectional Study of a National Network

It is important to use evidence-based programs and practices (EBPs) to address major public health issues. However, those who use EBPs in real-world settings often require support in bridging the research-to-practice gap. In the US, one of the largest systems that provides such support is the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Technology Transfer Center (TTC) Network. As part of a large external evaluation of the Network, this study examined how TTCs determine which EBPs to promote and how to promote them. Using semi-structured interviews and pre-testing, we developed a "Determinants of Technology Transfer" survey that was completed by 100% of TTCs in the Network. Because the study period overlapped with the onset of the COVID-19 pandemic, we also conducted a retrospective pre/post-pandemic comparison of determinants. TTCs reported relying on a broad group of factors when selecting EBPs to disseminate and the methods to do so. Stakeholder and target audience input and needs were consistently the most important determinant (both before and during COVID-19), while some other determinants fluctuated around the pandemic (e.g., public health mandates, instructions in the funding opportunity announcements). We discuss implications of the findings for technology transfer and frame the analyses in terms of the Interactive Systems Framework for Dissemination and Implementation.

Effects of Training in Cognitive Behavioural Therapy and Motivational Interviewing on Mental Health Practitioner Behaviour: A Systematic Review and Meta-Analysis

Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face-to-face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta-analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta-analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face-to-face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta-analyses. Future directions are discussed.

Enhancing the SUSTAINable uptake of evidence to minimise harms from alcohol and other drugs in New South Wales, Australia

Although alcohol and other drug use is increasingly the focus of policy and research efforts, there are challenges identifying and applying evidence-based strategies to minimise harms for alcohol and other drugs in health care and community settings. These challenges include limited available research, variability across settings, and lack of 'fit' between research evidence and their intended settings. In this commentary, we describe a novel approach to develop and evaluate tailored, sustainable strategies to enhance the uptake of evidence-based activities into health services and community settings. Our approach involves four key principles: (i) identifying evidence-based alcohol and other drug harm minimisation strategies; (ii) partnering with local experts to identify and tailor strategies; (iii) implementing strategies into existing practice/infrastructure to build in sustainability; and (iv) using sustainable co-designed outcome measures including value-based health-care principles to measure uptake, feasibility and acceptability, health outcomes and economic implications. We propose that this approach offers a way forward to enhance the relevance and suitability of research in health services and community settings and has potential to be applied in other sectors.

A Statewide Randomized Controlled Trial to Compare Three Models for Implementing Parent Child Interaction Therapy

OBJECTIVE

This study (NIMH RO1 MH095750; ClinicalTrials.gov Identifier: NCT02543359) evaluated the effectiveness of three training models to implement a well-established evidence-based treatment, Parent-Child Interaction Therapy (PCIT).

METHOD

Fifty licensed outpatient clinics, including 100 clinicians, 50 supervisors, and 50 administrators were randomized to one of three training conditions: 1) Learning Collaborative (LC), 2) Cascading Model (CM) or 3) Distance Education (DE). Data to assess training and implementation outcomes were collected at 4 time points coinciding with the training period: baseline, 6- (mid), 12- (post), and 24-months (1-year follow-up).

RESULTS

Multi-level hierarchical linear growth modeling was used to examine changes over time in training outcomes. Results indicate that clinicians in CM were more likely to complete training, reported high levels of training satisfaction and better learning experiences compared to the other training conditions. However, supervisors in the LC condition reported greater learning experiences, higher levels of knowledge, understanding of treatment, and satisfaction compared to supervisors in other conditions. Although clinicians and supervisors in the DE condition did not outperform their counterparts on any outcomes, their performance was comparable to both LC and CM in terms of PCIT use, supervisor perceived acceptability, feasibility, system support, and clinician satisfaction.

CONCLUSIONS

Through the use of a randomized controlled design and community implementation, this study contributes to the current understanding of the impact of training design on implementation of PCIT. Results also indicate that although in-person training methods may produce more positive clinician and supervisor outcomes, training is not a one-size-fits-all model, with DE producing comparable results on some variables.

Virtual reality (VR) treatments for anxiety disorders are unambiguously successful, so why are so few therapists using it? Barriers to adoption and potential solutions

Anxiety disorders are a significant cause of disability globally, yet only one in ten sufferers receives adequate quality treatment. Exposure-based therapies are effective in reducing symptoms associated with a number of anxiety disorders. However, few therapists use exposure techniques to treat these conditions, even when they are adequately trained in them, often because of concerns about provoking distress, drop out, logistical barriers, and other concerns. Virtual reality exposure therapy (VRET) can address many of these concerns, and a large body of research decisively shows that VRET is as efficacious for treating these conditions as in vivo exposures. Yet, use of VRET remains low. In this article, we discuss several factors we believe are contributing to low VRET adoption among therapists and raise potential solutions to address them. We consider steps that VR experience developers and researchers might take, such as leading studies of VRET's real-world effectiveness and treatment optimization trials and continuing to improve the fit of platforms with clinicians' workflows. We also discuss steps to address therapist reservations using aligned implementation strategies, as well as barriers for clinics, and the roles that professional organizations and payers could have in improving care by encouraging adoption of VRET.

Community selected strategies to reduce opioid-related overdose deaths in the HEALing (Helping to End Addiction Long-term SM) communities study

The Helping End Addictions Long Term (HEALing) Communities Study (HCS) seeks to significantly reduce overdose deaths in 67 highly impacted communities in Kentucky (KY), Massachusetts (MA), New York (NY), and Ohio (OH) by implementing evidence-based practices (EBPs) to reduce overdose deaths. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA) organizes EBP strategies under three menus: Overdose Education and Naloxone Distribution (OEND), Medication Treatment for Opioid Use Disorder (MOUD), and Safer Prescribing and Dispensing Practices (SPDP). The ORCCA sets requirements for strategy selection but allows flexibility to address community needs. This paper describes and compiles strategy selection and examines two hypotheses: 1) OEND selections will differ significantly between communities with higher versus lower opioid-involved overdose deaths; 2) MOUD selections will differ significantly between urban versus rural settings.

METHODS

Wave 1 communities (n = 33) provided data on EBP strategy selections. Selections were recorded as a combination of EBP menu, sector (behavioral health, criminal justice, and healthcare), and venue (e.g., jail, drug court, etc.); target medication(s) were recorded for MOUD strategies. Strategy counts and proportions were calculated overall and by site (KY, MA, NY, OH), setting (rural/urban), and opioid-involved overdose deaths (high/low).

RESULTS

Strategy selection exceeded ORCCA requirements across all 33 communities, with OEND strategies accounting for more (40.8%) than MOUD (35.1%), or SPDP (24.1%) strategies. Site-adjusted differences were not significant for either hypothesis related to OEND or MOUD strategy selection.

CONCLUSIONS

HCS communities selected strategies from the ORCCA menu well beyond minimum requirements using a flexible approach to address unique needs.

Untreated substance use disorder affects glycemic control: Results in patients with type 2 diabetes served within a network of community-based healthcare centers in Florida

Introduction

Patients with diabetes and comorbid substance use disorders (SUD) experience poor diabetes management, increased medical complications and mortality. However, research has documented that patients engaged in substance abuse treatment have better management of their comorbid conditions. The current study examines diabetes management among patients with type 2 diabetes, with and without comorbid SUD, receiving care at Florida-based Federally Qualified Health Centers (FQHC) of Health Choice Network (HCN).

Methods

A retrospective analysis was conducted using deidentified electronic health records of 37,452 patients with type 2 diabetes who received care at a HCN site in Florida between 2016 and 2019. A longitudinal logistic regression analysis examined the impact of SUD diagnosis on achievement of diabetes management [HbA1c < 7.0% (53 mmol/mol)] over time. A secondary analysis evaluated, within those with an SUD diagnosis, the likelihood of HbA1c control between those with and without SUD treatment.

Results

The longitudinal assessment of the relationship between SUD status and HbA1c control revealed that those with SUD (N = 6,878, 18.4%) were less likely to control HbA1c over time (OR = 0.56; 95% CI = 0.49-0.63). Among those with SUD, patients engaged in SUD treatment were more likely to control HbA1c (OR = 5.91; 95% CI = 5.05-6.91).

Discussion

Findings highlight that untreated SUD could adversely affect diabetes control and sheds light on the opportunity to enhance care delivery for patients with diabetes and co-occurring SUD.

Dissemination of Contingency Management for the Treatment of Opioid Use Disorder

Contingency management is an intervention for substance use disorders based on operant principles. The evidence base in support of contingency management is massive. It is effective in treating substance use disorder in general and opioid use disorder in particular. Dissemination has remained slow despite the urgency created by the opioid epidemic. Key barriers include a lack of expertise, time, and money. Implementing contingency management with smartphones eliminates the need for special training. It also solves logistical issues and requires little time on the part of clinicians. Thus, remaining barriers relate to cost. Federal anti-kickback regulations complicate solutions to the cost barrier. Other important regulatory challenges related to cost include the lack of billing codes and the difficulty of obtaining FDA approval for digital therapeutics. Even after the cost barrier is overcome, provider adoption is not guaranteed. Incentivizing providers for collaborative care may increase adoption and generate referrals. Recently proposed legislation and governmental policy statements provide optimism regarding the near-term large-scale adoption of contingency management in the treatment of opioid use disorder.

Perspectives of researchers with lived experience in implementation science research: Opportunities to close the research-to-practice gap in substance use systems of care

Background

The field of implementation science acknowledges the importance of diversity within research teams including members from diverse disciplines and with lived expertise in practical implementation (e.g., administrators, front-line workers, patients/clients). Gaps remain in the successful implementation of proven substance use treatment interventions.

Methods

This paper will outline the rationale for the purposeful inclusion of researchers with lived experience (RLE) related to substance use disorder (SUD) within implementation science research studies focused on improving SUD services.

Results

We posit that researchers with such experience can help address research-to-practice gaps by (1) building strong community partnerships, (2) engaging in conversations around effective interventions through knowledge translation, (3) providing community-congruent approaches to evaluation, and (4) aiding in dissemination and sustainability efforts.

Conclusions

We end by offering recommendations for researchers without lived experience as they intentionally collaborate with RLE.

Community pharmacist intervention to close statin gaps in diabetes care: The GuIDE-S study

BACKGROUND

Statin therapy is recommended for people with type 2 diabetes (T2D) to lower cardiovascular risk; however, evidence suggests that significant gaps in statin therapy exist.

OBJECTIVE

To evaluate (1) the impact of a community pharmacist-led model for initiating statin therapy in people with type 2 diabetes (T2D) on statin initiation and (2) pharmacists' self-reported perceptions of the intervention feasibility and fidelity to the intervention.

METHODS

This was a type 1 hybrid effectiveness-implementation study of 9 intervention and 18 control pharmacies within a community pharmacy chain. Pharmacy staff proactively identified patients with T2D not taking a statin and prescribed a statin via a collaborative practice agreement or facilitated acquisition of a prescription from the patient's preferred prescriber. The eligible population included patients aged 18-84 years with T2D, who had filled ≥60 days' supply of one, noninsulin, diabetes medication in a rolling 6-month period, and who had not filled a statin during the same period. A Cox proportional hazards model was used to compare time to statin initiation. Pharmacists at intervention pharmacies completed a survey at 6 and 12 months after implementation (March and August 2019, respectively) to assess intervention feasibility and fidelity.

RESULTS

For the statin initiation analysis, 1670 intervention patients were matched to 3358 control patients. Overall, 26.3% (n=442) of intervention patients and 25.4% (n=854) of control patients initiated a statin within 12 months of their index date. There was no difference in statin initiation likelihood between intervention and control patients (hazard ratio: 1.00; 95% CI: 0.83, 1.21). Fifteen pharmacists completed the 6-month survey (33% response rate), and 12 completed the 12-month survey (26%). The intervention's feasibility score was 4.0 at 6 months and 4.2 at 12 months, indicating an increase in perceived feasibility. Fidelity decreased from 6 to 12 months.

CONCLUSION

The community pharmacist-led intervention resulted in more patients initiating statin therapy as compared to usual care; however, the differences were not statistically significant. Pharmacists perceived the intervention to be feasible; however, fidelity decreased over time.

Implementation of strengths model case management in seven mental health agencies in Canada: Direct-service practitioners' implementation experience

RATIONALE

Implementation of strengths model case management is increasing internationally. However, few studies have focused on its implementation process, and none have specifically addressed the implementation experience of direct-service practitioners.

OBJECTIVE

This paper presents factors that facilitate and impede the successful implementation of the strengths model, with a specific focus on practitioners who deliver the intervention directly to service recipients.

METHOD

To address this objective, a qualitative study of seven mental health agencies that implemented the model was conducted, involving a combination of participant observations and qualitative semistructured interviews with case managers, team supervisors, and senior managers. Qualitative data were analyzed using open coding followed by axial coding. Finally, the findings were aligned with an adapted Consolidated Framework for Implementation Research.

RESULTS

Implementation of the strengths model involved a significant change in practice for case management practitioners. The results confirm that at the beginning of implementation, the strengths model was perceived as complex and not always adaptable to on-the-ground realities. With time, and with support from management, ongoing training and supervision sessions, and reflection and discussion, practitioners regained feelings of competence and resistance to the model diminished. The use of the model's structured team-based supervision tools was fundamental to supporting the implementation process by enabling an interactive and concrete training approach.

CONCLUSIONS

The more an approach leads to changes in daily practice and is perceived as complex, the more concrete support is needed during implementation. This article highlights the importance of attending to a practitioner's sense of personal effectiveness and competence in the adoption of new practices.

Implementing Trauma Informed Care in Human Services: An Ecological Scoping Review

Trauma and toxic stress are growing public health concerns with increasing risks to morbidity and mortality. Trauma informed care is an organizational response that challenges providers to adapt principled based approaches that seek to reduce adverse effects of care and support healing. However, there is a scarcity of empirical evidence on how trauma informed care is implemented in systems. A preferred reporting items for systematic reviews and meta-analysis-compliant scoping review based on Arksey, and O’Malley’s five steps model was conducted. Four databases, PubMed, Scopus, Embase and PsychINFO were searched for English articles published since 2000. Studies were included if they reported on trauma informed care delivered by services that support adults and there was some reference to implementation or organizational implications. Of 1099 articles retrieved, 22 met the inclusion criteria. Findings suggest that trauma informed care is being implemented in a range of human services, including at the city/state level. While implementation research is still at an early stage in this field, the findings elucidate several challenges when implementing this approach across systems of care. An ecological lens is used to present findings at the macro, mezzo, and micro level, and these are further discussed with reference to practice, policy, and research.

Virtual Training Is More Cost-Effective Than In-Person Training for Preparing Staff to Implement Contingency Management

Behavior therapy implementation relies in part on training to foster counselor skills in preparation for delivery with fidelity. Amidst Covid-19, the professional education arena witnessed a rapid shift from in-person to virtual training, yet these modalities' relative utility and expense is unknown. In the context of a cluster-randomized hybrid type 3 trial of contingency management (CM) implementation in opioid treatment programs (OTPs), a multi-cohort design presented rare opportunity to compare cost-effectiveness of virtual vs. in-person training. An initial counselor cohort (n = 26) from eight OTPs attended in-person training, and a subsequent cohort (n = 31) from ten OTPs attended virtual training. Common training elements were the facilitator, learning objectives, and educational strategies/activities. All clinicians submitted a post-training role-play, independently scored with a validated fidelity instrument for which performances were compared against benchmarks representing initial readiness and advanced proficiency. To examine the utility and expense of in-person and virtual trainings, cohort-specific rates for benchmark attainment were computed, and per-clinician expenses were estimated. Adjusted between-cohort differences were estimated via ordinary least squares, and an incremental cost effectiveness ratio (ICER) was calculated. Readiness and proficiency benchmarks were attained at rates 12-14% higher among clinicians attending virtual training, for which aggregated costs indicated a $399 per-clinician savings relative to in-person training. Accordingly, the ICER identified virtual training as the dominant strategy, reflecting greater cost-effectiveness across willingness-to-pay values. Study findings document greater utility, lesser expense, and cost-effectiveness of virtual training, which may inform post-pandemic dissemination of CM and other therapies.

Attitudes and experiences towards the application of motivational interviewing by podiatrists working with people with diabetes at high-risk of developing foot ulcers: a mixed-methods study

Background

Podiatrists are key professionals in promoting adequate foot self-care for people with diabetes at high-risk of developing foot ulcers. However, merely informing patients about the advantages of foot self-care is insufficient to realise behavioural change. Motivational interviewing (MI) is a promising person-centred communication style that could help to create a working alliance between healthcare providers and patient to improve foot self-care. This study aims to observe and analyse the application of MI in consultations carried out by MI-trained and non-MI-trained podiatrists with their patients, and explore podiatrists’ attitudes and experiences towards MI.

Methods

Eighteen podiatrists (median age: 28.5 years, 10 female and 8 male) followed a three-day basic training in MI and 4 podiatrists (median age: 38.5 years, 4 female) were not trained in MI. To observe and rate the MI-fidelity in daily clinical practice, audio recordings from the MI-trained and non-MI-trained podiatrists were scored with the Motivational Interviewing Treatment Integrity code. Individual, semi-structed, in-depth interviews were conducted with the MI-trained podiatrists to explore their attitudes towards and experiences with MI. These data sources were triangulated to describe the effect of training podiatrists in MI for their clinical practice.

Results

The MI-trained podiatrists scored significantly higher than the non-MI-trained podiatrists on two of four global MI-related communication skills (empathy, p = 0.008 and change talk, p = 0.008), on one of five core MI-adherent behaviours (affirmation, p = 0.041) and on one of the other behaviour counts (simple reflections, p = 0.008). The podiatrists mainly reported their attitudes and experiences regarding partnership and cultivating change talk, during the interviews. In addition, they also mentioned facilitators and barriers to using MI and indicated whether they experienced MI as having added value.

Conclusions

The MI-trained podiatrists used the principles of MI at a solid beginner proficiency level in their clinical practice in comparison to the non-MI-trained podiatrists, who did not reach this level. This achievement is in accordance with the basic MI-training they received. This multi-method study reveals that podiatrists can be effectively trained in applying MI in daily clinical practice.

Trial registration

Netherlands Trial Register NL7710. Registered: 6 May 2019.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research

PURPOSE

To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula.

METHOD

The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability.

RESULTS

Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula.

CONCLUSIONS

SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

Implementing and Sustaining Brief Addiction Medicine Interventions with the Support of a Quality Improvement Blended-eLearning Course: Learner Experiences and Meaningful Outcomes in Kenya

Quality improvement methods could assist in achieving needed health systems improvements to address mental health and substance use, especially in low-middle-income countries (LMICs). Online learning is a promising avenue to deliver quality improvement training. This Computer-based Drug and Alcohol Training Assessment in Kenya (eDATA-K) study assessed users’ experience and outcome of a blended-eLearning quality improvement course and collaborative learning sessions. A theory of change, developed with decision-makers, identified relevant indicators of success. Data, analyzed using descriptive statistics and thematic analysis, were collected through extensive field observations, the eLearning platform, focus group discussions, and key informant interviews. The results showed that 22 community health workers and clinicians in five facilities developed competencies enabling them to form quality improvement teams and sustain the new substance-use services for the 8 months of the study, resulting in 4591 people screened, of which 575 received a brief intervention. Factors promoting course completion included personal motivation, prior positive experience with NextGenU.org’s courses, and a certificate. Significant challenges included workload and network issues. The findings support the effectiveness of the blended-eLearning model to assist health workers in sustaining new services, in a supportive environment, even in a LMIC peri-urban and rural settings.

Policy Makers' Priorities for Addressing Youth Substance Use and Factors That Influence Priorities

OBJECTIVE

Understanding public policy makers' priorities for addressing youth substance use and the factors that influence these priorities can inform the dissemination and implementation of strategies that promote evidence-based decision making. This study characterized the priorities of policy makers in substance use agencies of U.S. states and counties for addressing youth substance use, the factors that influenced these priorities, and the differences in priorities and influences between state and county policy makers.

METHODS

In 2020, a total of 122 substance use agency policy makers from 35 states completed a Web-based survey (response rate=22%). Respondents rated the priority of 14 issues related to youth substance use and the extent to which nine factors influenced these priorities. Data were analyzed as dichotomous and continuous variables and for state and county policy makers together and separately.

RESULTS

The highest priorities for youth substance use were social determinants of substance use (87%), adverse childhood experiences and childhood trauma (85%), and increasing access to school-based substance use programs (82%). The lowest priorities were increasing access to naloxone for youths (49%), increasing access to medications for opioid use disorder among youths (49%), and deimplementing non-evidence-based youth substance use programs (41%). The factors that most influenced priorities were budget issues (80%) and state legislature (69%), federal (67%), and governor priorities (65%). Issues related to program implementation and deimplementation were significantly higher priorities for state than for county policy makers.

CONCLUSIONS

These findings can inform the tailoring of dissemination and implementation strategies to account for the inner- and outer-setting contexts of substance use agencies.

Automated evaluation of psychotherapy skills using speech and language technologies

With the growing prevalence of psychological interventions, it is vital to have measures which rate the effectiveness of psychological care to assist in training, supervision, and quality assurance of services. Traditionally, quality assessment is addressed by human raters who evaluate recorded sessions along specific dimensions, often codified through constructs relevant to the approach and domain. This is, however, a cost-prohibitive and time-consuming method that leads to poor feasibility and limited use in real-world settings. To facilitate this process, we have developed an automated competency rating tool able to process the raw recorded audio of a session, analyzing who spoke when, what they said, and how the health professional used language to provide therapy. Focusing on a use case of a specific type of psychotherapy called "motivational interviewing", our system gives comprehensive feedback to the therapist, including information about the dynamics of the session (e.g., therapist's vs. client's talking time), low-level psychological language descriptors (e.g., type of questions asked), as well as other high-level behavioral constructs (e.g., the extent to which the therapist understands the clients' perspective). We describe our platform and its performance using a dataset of more than 5000 recordings drawn from its deployment in a real-world clinical setting used to assist training of new therapists. Widespread use of automated psychotherapy rating tools may augment experts' capabilities by providing an avenue for more effective training and skill improvement, eventually leading to more positive clinical outcomes.

Game Plan-a Brief Web-Based Intervention to Improve Uptake and Use of HIV Pre-exposure Prophylaxis (PrEP) and Reduce Alcohol Use Among Gay and Bisexual Men: Content Analysis

Background

HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings.

Objective

We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale.

Methods

Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys.

Results

In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set.

Conclusions

Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

Integration of Twelve Step with Evidence-Based Practices in a Residential Treatment Center

Background: Residential treatment for substance use disorders (SUDs) typically involves both medical and psychological treatments to best meet the needs of service users. Common treatments include Twelve Step Facilitation (TSF) as well as evidence-based practices (EBPs) such as cognitive behavioral therapies and medications. Researchers have discussed the difficulties with implementation and sustainability of EBPs within treatment centers that predominantly use TSF. Objectives: Understanding the process of implementation is an important area of study to inform future implementation efforts. The present study involved a qualitative investigation of a residential treatment center that integrated EBPs alongside TSF. Treatment stakeholders (N=22) were interviewed about their experience with integration. Results: The results indicated that the organization's evolution to integrate evidence-based practices (e.g., medication, evidenced-based psychotherapy) occurred through a process of themes including staff members' personal allegiance to Twelve Step; tension among staff members; staff collaboration; and integration of theoretical orientations. The results parallel those found in the Normalization Process Theory of implementation. Conclusions: The present study provides an understanding as to how Twelve Step and EBPs can be integrated into a residential treatment center, allowing for service users to have choice in their care. The program's ability to navigate the treatment evolution can be used as an example for integrating evidence-based practice with Twelve Step to meet the many needs of individuals seeking substance use treatment.

Game Plan, a Web-Based Intervention to Improve Adherence and Persistence to HIV Pre-exposure Prophylaxis and Reduce Heavy Drinking in Gay, Bisexual, and Other Men Who Have Sex With Men: Usability and User Experience Testing

Background

Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use.

Objective

The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP.

Methods

In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data.

Results

Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site’s content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website’s esthetics to the participants’ engagement with it and its credibility in prompting genuine reflection.

Conclusions

GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.

The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

BACKGROUND

First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders' access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes.

METHODS

A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks.

RESULTS

Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership's positive relationship with providers' EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers' role in implementation.

CONCLUSIONS

Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation.

TRIAL REGISTRATION

This review was not registered.

Parent SMART (Substance Misuse in Adolescents in Residential Treatment): Pilot randomized trial of a technology-assisted parenting intervention

Adolescents in residential level of care for substance-related problems have high risk of relapse following discharge. Parent engagement lowers relapse risk, but there are myriad barriers to engaging parents in residential treatment and continuing care. Parent SMART (Substance Misuse in Adolescents in Residential Treatment) is a technology-assisted parenting intervention that was designed to circumvent barriers associated with traditional, office-based continuing care interventions to better engage parents. This pilot randomized trial assessed the acceptability, feasibility, and preliminary effectiveness of Parent SMART as an adjunctive intervention to adolescent residential treatment-as-usual (TAU). Sixty-one parent-adolescent dyads were randomized to Parent SMART+TAU or TAU-only. Thirty-seven dyads were recruited from a short-term facility and 24 dyads were recruited from a long-term facility. Those randomized to Parent SMART received a multi-component technology-assisted intervention combining an off-the-shelf online parenting program, coaching sessions, and a parent networking forum. Parent and adolescent assessments were conducted at baseline, 6, 12, and 24-weeks post-discharge. Feasibility (e.g., parental effectiveness) and acceptability (e.g., parental satisfaction, willingness to recommend the intervention) benchmarks were specified a priori as the primary hypotheses. Secondary effectiveness indicators were the proportion of days adolescent used alcohol, cannabis, and any substance. All acceptability and feasibility benchmarks were met or exceeded among dyads in both short- and long-term residential. Generalized linear mixed models showed no significant effects pooled across sites. Analyses by facility revealed two significant time by condition interactions. Adolescents in short-term residential whose parents received Parent SMART showed fewer drinking days and fewer school problems over time, relative to adolescents whose parents received TAU. Results indicate that Parent SMART was both acceptable and feasible, with preliminary indication of effectiveness among those in short-term residential. A fully-powered trial is warranted to reliably test the effectiveness of Parent SMART and understand possible mechanisms of improvement.

Evaluation of an online motivational interviewing training program for rehabilitation professionals: A pilot study

OBJECTIVE

To investigate the feasibility and effectiveness of an online motivational interviewing training program for rehabilitation professionals.

DESIGN

Pre-post design with two groups.

SETTING

Private rehabilitation hospital and an academic medical center.

SUBJECTS

Group 1 included 19 motivational interviewing-experienced rehabilitation professionals. Group 2 included 25 motivational interviewing-naïve rehabilitation professionals.

INTERVENTIONS

Group 1 was exposed to an online motivational training program and Group 2 was exposed to an online motivational training program and a live booster session.

MAIN MEASURES

Motivational interviewing communication skills were measured with an adapted Helpful Responses Questionnaire. Knowledge and attitudes were measured with an adapted Motivational Interviewing Knowledge and Attitudes Test. Confidence, importance, and feasibility for implementing motivational interviewing were measured using the Motivational Interviewing Rulers.

RESULTS

Group 1 showed improvement in communication skills (2.6/5-3.3/5; P < 0.05) and confidence (6.0/01-7.4/10; P < 0.01) after online training. Improvements seen in skills and confidence were maintained at three months. Group 2 showed improvement in skills (2.1/5-3.3/5; P < 0.001), knowledge (7.7/10-8.5/10; P < 0.01), confidence (6.4/10-7.5/10; P < 0.01), and importance (8.3/10-8.9/10; P < 0.05) after online training. At three-months post-booster, improvements in communication skills and knowledge were maintained.

CONCLUSIONS

Online training can be a cost and time effective approach to improve rehabilitation professionals' skills in motivational interviewing. Follow-up training activities are needed to maintain the level of knowledge and skill improvement.

Implementation Factors for the Delivery of Alcohol and Drug Interventions to Children in Care: Qualitative Findings from the SOLID Feasibility Trial

Young people in care have a four-fold increased risk of drug and alcohol use compared to their peers. The SOLID study aimed to deliver two behaviour change interventions to reduce risky substance use (illicit drugs and alcohol) and improve mental health in young people in care. The study was carried out in 6 local authorities in the North East of England. Young people in care aged 12–20 years, who self-reported substance use within the previous 12 months were randomised to Motivational Enhancement Therapy, Social Behaviour and Network Therapy or control. In-depth 1:1 interviews and focus groups were used with young people in care, foster carers, residential workers, social workers and drug and alcohol practitioners to explore the key lessons from implementing the interventions. The Consolidated Framework of Implementation Research framed the analysis. Findings illustrated that the everyday interaction between individuals, service level dynamics and external policy related factors influenced the implementation of these new interventions at scale. We concluded that unless interventions are delivered in a way that can accommodate the often-complex lives of young people in care and align with the drug and alcohol practitioners’ and social workers priorities, it is unlikely to be successfully implemented and become part of routine practice.

People who use drugs in rehabilitation, from chaos to discipline: Advantages and pitfalls: A qualitative study

Evidence-based models emphasizing on lifestyle behaviours for the treatment of drug use is still in its infancy. The development of multicomponent effective drug use intervention programs as part of health promotion is crucial to decrease risk of relapse. This study aims at exploring the lifestyle practices including dietary intake, physical activity and sleep of people who use drugs undergoing residential rehabilitation treatment in Lebanon with its perceived benefits and pitfalls. A purposive sample of 18 males and 9 females at different stages of recovery from drug use in rehabilitation centers participated in the qualitative discussions. The six phases thematic analysis revealed three themes: chaotic lifestyle, structuredlifestyle, benefits and pitfalls, and suggestions for making rehabilitation a better experience. Participants discussed their chaotic lifestyle during addiction with poor food intake, disrupted sleep and low physical activity moving to a more disciplined routine enforcing normality in lifestyle practices with social and professionlprofessional support. The early phases of treatment were marked with increased food intake and weight gain perceived as a health indicator and the sole divergent from drugs, moving towards more structured meals and efforts to lose weight in later stages. Lack of variety of Physical activity programs taking into consideration the motivational differences among the participants was also highlighted. Measures for improving rehabilitation services in terms of promoting healthy eating behaviours and environmental control were thoroughly addressed. These findings shed the light on the challenges faced in maintaining a healthy lifestyle in rehabilitation centers and the necessities of addressing them to improve the overall rehabilitation experience, prevent relapse and inform the development of future targeted intervention programs tackling all aspects of behavioural changes.

Practice and Dissemination of Motivational Interviewing: A Psychology Internship Curriculum

Sufficient training in substance use issues has been identified as a common gap in professional psychology graduate training. Satisfactory training in evidence-based practices has also been identified as a common gap for providers who care for individuals with substance use problems. The "practice and dissemination" curriculum we developed seeks to address both of these gaps during the predoctoral internship training year by first training psychology interns to competently deliver motivational interviewing (MI) to individuals with substance use problems and then train community providers and volunteers to do so. From 2012-2013, a total of 55 community providers and volunteers from a homeless shelter, a substance use treatment facility, and a community mental health facility received training in MI through this curriculum by attending continuing education events delivered by 17 psychology interns. Evaluation of the dissemination portion of the curriculum as part of an exempt educational research project revealed that community providers were able to achieve significant increases in MI knowledge, readiness to implement MI, and MI skill as assessed with a video analogue measure by the end of the workshop. They also reported satisfaction with the workshop. These evaluation findings provide preliminary support for the curriculum as a novel and efficacious way to disseminate MI to community providers. Research is necessary to determine long-term outcomes of such training and to identify strategies to overcome potential barriers such as the substantial faculty effort necessary to implement the intensive curriculum.

Program development and implementation outcomes of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS)

Background: As the opioid epidemic continues, there is a mounting sense of urgency to improve access to high-quality early identification and treatment services. However, the need is outpacing capacity in many states and effective solutions to support primary care and specialty prescribers to identify and treat more patients with opioid use disorders are still emerging. This paper describes one state's approach to increase access to medication for opioid use disorders (MOUD) through development and implementation of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS). Methods: Program components include a warmline, outreach and training, and resource and referral linkages for prescribers based on related consultation service models and documented barriers to prescribing MOUDs. Results: Initial implementation outcomes indicate service components are being adopted as intended and by the target audience; many prescribers who engaged with the service have their buprenorphine waiver (44%) but do not have any additional formal addiction training (57%). Also, statewide penetration is promising with prescriber engagement in 100% of counites, however only 33% of counties in engaged in all four types of MACS services. Most calls (61%) originated from urban counties. Conclusions: The MACS program increases access to specialty addiction medicine consultation and training through use of technology. MACS can serve as a model for other states looking to bridge the gap in access to addiction treatment.

Program Evaluation of Group Transcending Self Therapy: An Integrative Modular Cognitive-Behavioral Therapy for Substance Use Disorders

OBJECTIVES

Substance Use Disorders (SUDs) are increasingly prevalent among Veterans. Effective interventions for SUDs that also meet the clinical reality of open treatment groups are needed. Transcending Self Therapy: Group Integrative Cognitive Behavioral Treatment (Group TST-I-CBT) was developed to address this need. Group TST-I-CBT is a four-module, 20-session treatment designed so that a person can enter at any point in the treatment. We conducted a program evaluation of Group TST-I-CBT for veterans with SUDs.

METHODS

Participants were N = 68 veterans enrolled in the 28-day Substance Abuse Residential Rehabilitation Treatment Program at an urban Veterans Administration Medical Center who received either Group TST-I-CBT (N = 34) or treatment-as-usual (TAU; N = 34). Medical records were reviewed and participant treatment outcome data was retrieved. Group TST-I-CBT clients completed a knowledge and feedback form at treatment completion.

RESULTS

Compared to TAU participants, Group TST-I-CBT participants were significantly less likely to have a positive urine drug screen (UDS) during treatment (17.6% versus 0%; P = .01) and within one month post-discharge (50% versus 17.6%; P = .04). Among Group TST-I-CBT clients, Quality of Life Inventory scores significantly increased by an average of 14 points from pre- to post-treatment, t(15) = -3.31, P = .005, d = 0.83. Group TST-I-CBT clients displayed cognitive-behavioral therapy knowledge (mean correct answers ranged from 92%-100%) and rated Group TST-I-CBT as helpful, understandable, and useful (mean scores ranged from 9.3-9.6 out of 10).

CONCLUSIONS

These preliminary data indicate that Group TST-I-CBT may be an effective group therapy as part of SUD treatment. A formal randomized controlled trial of Group TST-I-CBT may be warranted.

Validation of a pragmatic measure of implementation citizenship behavior in substance use disorder treatment agencies

The organizational context in which substance use disorder treatment (SUDT) evidence-based practices (EBPs) are implemented plays a critical role in successful implementation. Employee behaviors that go above and beyond typical job requirements to support EBP implementation have been suggested to facilitate the likelihood of overall implementation success. The current study explored the psychometric properties of the Implementation Citizenship Behavior Scale (ICBS) within SUDT settings. Utilizing a sample of 322 direct service providers and 60 of their respective supervisors from three SUDT agencies, results from a confirmatory factor analysis and construct validity analysis support the use of the ICBS in the SUDT context. Validation of the ICBS provides a useful, pragmatic tool for both researchers and practitioners to assess employee citizenship behavior to support EBP implementation. The ICBS can provide critical insights into how providers respond to organizational context that may facilitate EBP implementation.

Technology-Delivered Interventions for Substance Use Among Adolescents

Unhealthy alcohol and drug use are common among adolescents. A range of evidence-based interventions are available, but are rarely accessed by adolescents because of barriers such as cost, limited dissemination, lack of motivation to change, and logistical obstacles such as lack of transportation. Technology-delivered approaches may facilitate receipt of treatment in this vulnerable population. The limited number of controlled trials in this area present a mixed picture in terms of efficacy. Although sufficient to merit close attention and expanded research, the current literature points to a strong need for larger samples and greater use of rigorous and replicable methods.

Race/Ethnicity, Community of Residence, and DUI Arrest After Beginning Treatment for an Alcohol Use Disorder

The purpose of this study was to examine whether racial/ethnic disparities in post-treatment arrests for driving under the influence (DUI) exist among clients receiving outpatient treatment for an alcohol use disorder (AUD) and to assess whether community characteristics were associated with this outcome. The sample included adults with an AUD entering publicly funded outpatient treatment in Washington State in 2012. Treatment data were linked with criminal justice and US Census data. Multilevel time-to-event analysis was employed to answer the research questions. Key independent variables included client race/ethnicity, community-level economic disadvantage, and racial/ethnic composition of the community. Latino clients and clients residing in communities with a higher proportion of Black residents had higher hazards of a DUI arrest post-treatment admission. Future research should examine whether disparities in DUI arrests are related to differences in treatment effectiveness or other factors (e.g., inequities in law enforcement) so that these disparities can be addressed.

Understanding site variability in a multisite clinical trial of a technology-delivered psychosocial intervention for substance use disorders

BACKGROUND

Significant fixed effects of site (main effects of site and/or site by treatment interactions) on primary outcome have been identified in the majority of studies performed by NIDA's National Drug Abuse Treatment Clinical Trials Network. While rarely explored, identifying patient- and site-level variables that are associated with site effects can provide information about the context in which outcome is optimized.

METHODS

In a 10-site clinical trial that evaluated the effectiveness of a web-based psychosocial intervention compared to usual treatment of patients (N = 507) with substance use disorders, the primary outcome analysis revealed significant main effect of site, modeled as a fixed effect, on the outcome of abstinence (Campbell et al., 2014). In the current analysis, we use a two-level, hierarchical generalized linear model (HGLM) to identify patient- and site-level variables associated with abstinence outcome, while modeling site as a random factor.

RESULTS

The site-specific percentage of patients abstinent in the last 4 weeks of the study varied from 6.1% to 40%. However, only 6.7% (p = 0.08) of variability in end-of-study abstinence was accounted for by site, indicating a small-moderate effect. Among patient-level predictors, older age (OR = 1.40; 95% CI = 1.15, 1.71; p = 0.0009), abstinence at baseline (OR = 2.77; 95% CI = 1.73, 4.45; p < 0.0001), and among site-level predictors, higher annual clinic admissions (OR = 1.28; 95% CI = 1.03, 1.59; p = 0.0251) were significantly associated with increased likelihood of abstinence. When controlling for these three variables in a HGLM, only patient age and abstinence at baseline remained significant, and random factor site explained only 1.4% of variability in end-of-study abstinence, a 79% reduction in magnitude.

CONCLUSIONS

The findings suggest that only some amount of variability in abstinence outcomes among sites can be explained by a combination of patient- and site-level variables. Our findings support the case that variability between sites is a natural phenomenon, and our methodological recommendation is that site be modeled as a random factor when analyzing multi-site clinical trials.

Validation of the Implementation Climate Scale (ICS) in substance use disorder treatment organizations

Background

One critical factor in the implementation of evidence-based practice (EBP) in substance use disorder treatment organizations is an inner organizational context that clearly supports implementation efforts. The Implementation Climate Scale (ICS) has been developed to allow researchers and organizations to assess climate for EBP implementation in health and allied health service organizations. The ICS consists of 18 items and measures six dimensions of implementation climate: focus on EBP, educational support for EBP, recognition for EBP, rewards for EBP, selection for EBP, and selection for openness. The ICS was initially developed in a mental health context; thus, the goal of this study was to provide initial validation of the ICS in substance use disorder (SUD) treatment settings.

Methods

Confirmatory factor analysis (CFA) was used to assess the psychometric functioning of the ICS using survey data from 326 providers in 65 teams in SUD treatment programs. Cronbach’s alpha was examined to assess internal consistency of the ICS, and individual and team level construct-based validity was examined by comparing its correlations with service climate, molar climate, and organizational change.

Results

We found evidence for the reliability, factor structure, and validity of the ICS in SUD services. The psychometric functioning of the ICS in SUD treatment settings was comparable to that found in mental health contexts.

Conclusions

The ICS is a brief and pragmatic tool for researchers to better understand a critical antecedent for implementation effectiveness in SUD treatment and for organizational leaders in SUD treatment organizations to evaluate the extent to which providers perceive that their organization supports EBP implementation.

Measuring Treatment Integrity: Use of and Experience with Measurements in Child and Youth Care Organizations

Performance feedback and supervision are essential to the adoption of evidence-based interventions with high treatment integrity in child and youth care organizations. Little is known about the use of treatment integrity measurements in these organizations. For this study, 12 interventions for children and young people in the Netherlands with externalizing behavioral problems were selected. For each intervention, an expert, two supervisors, and two therapists were approached for an interview. In total, 54 semi-structured interviews were conducted. The results show that almost all interventions used treatment integrity instruments (N = 11, 91.7%). Only two used measurements for both QA procedures (certification and recertification) and supervision purposes. Therapists regard treatment integrity measurements as valuable when they are used for multiple purposes and feedback is provided. The results of this study suggest the feasibility of the use of measurements for multiple purposes. Collaborative action is required to develop instruments that effectively contribute to continuous improvement.

Group Cohesion and Climate in Cognitive Behavioral Therapy for Individuals with a First-Time DUI

Few studies have examined group cohesion and climate in the substance use disorder treatment literature. We examined whether group cohesion and climate are associated with increased self-efficacy outcomes and reduced drinks per week, binge drinking and DUI behaviors, in a sample of individuals with a first-time DUI receiving either cognitive behavioral therapy (CBT) or usual care. Additionally, we examined whether CBT moderates these relationships. Group measures and drinking outcomes were not significantly associated. This study is the first to provide an in-depth analysis on group processes in DUI settings, and as such, provides important insights into how group processes may differ in a mandated DUI context.

Designing an Individually Tailored Multilevel Intervention to Increase Engagement in HIV and Substance Use Treatment Among People Who Inject Drugs With HIV: HPTN 074

People who inject drugs (PWID) face barriers to engagement in antiretro-viral treatment (ART) and medication-assisted treatment (MAT). We detail the design, rapid preparation and adaptation, and systematic implementation of a flexible, individually tailored intervention for PWID in multiple settings: Indonesia, Ukraine, and Vietnam. HPTN 074 integrated systems navigation and counseling to facilitate entry and adherence to ART and MAT. Site-level guidance on the intervention involved in-depth interviews (IDIs) among PWID and their supporters and site-specific document review. IDIs emphasized ART misinformation and importance of social support for adherence. The document review revealed differences in health care system barriers, requiring an intervention that was flexible and tailored enough to address key outcomes. Implementation included regular debriefs for iterative adaptations based on participants' needs, including booster counseling sessions and subsidizing pre-ART testing. HPTN 074 provides a unique framework implementing a flexible and scalable intervention to improve ART and MAT outcomes among PWID across multiple settings.

Are Grittier Front-Line Therapists More Likely to Implement Evidence-Based Interventions?

Substance use disorder remains a pervasive problem in the U.S. and elsewhere. Recent scholarship has explored therapist characteristics and evidence based intervention implementation in an attempt to improve client outcomes. One such construct that has received considerable attention is grit. People with high levels of grit tend to remain determined despite setbacks. This study sought to elucidate the relationship of grit to therapeutic alliance and attitudes towards evidence-based interventions in a sample of front-line therapist (n = 240). Grit was found to be positively associated with therapeutic alliance and correlated with favorable attitudes towards using proven practice. Findings suggest that gritty therapists may sustain the use of evidence based interventions in their usual services and have better client outcomes.

A New Community-Based Model for Training in Evidence-Based Psychotherapy Practice

It is critical that evidence-based practices (EBP's) be provided to patients. Efforts to train clinicians in the community in EBP's, however, has been hindered by a lack of resources and rigid and resource intensive models of training. We describe efforts to overcome these barriers in a large scale community-based training program for Interpersonal Psychotherapy implemented with over 1400 clinicians in Los Angeles working within the Los Angeles County Department of Mental Health public system of care. The program, described in detail, is a potential template for training for community-based clinicians in evidence-based psychotherapy practices.

Process Evaluation of a Community Outpatient Program Treating Substance Use Disorders

Addiction treatment can improve its impact by providing evidence-based care for the variety of problems that accompany substance use disorders. We conducted a retrospective evaluation of a new treatment program in California that aimed at providing multifaceted services through affiliated licensed and certified outpatient providers. The process evaluation used a logic model, focusing on program inputs, activities, and outputs, to understand the services received by the initial 18 clients who entered treatment. Outcomes for these patients were not assessed. Results indicated that clients received a variety of services: On average clients contracted for 118 treatment sessions and received 143 sessions. Among the many types of services provided, the most frequently received were integrative healthcare (averaging 42 sessions), group therapy (32 sessions), and individual therapy (32 sessions). This logic-model process evaluation indicated that a range of services were provided. The comprehensive approach may have promise for extending addiction treatment beyond its usual boundaries.

Inclusion of Alcoholic Associations Into a Public Treatment Programme for Alcoholism Improves Outcomes During the Treatment and Continuing Care Period: A 6-Year Experience

Aims

To investigate whether inclusion of self-help groups into the hospital treatment programme improves the prognosis of alcohol dependence through the treatment period; and to examine therapeutic adherence and prognosis during continuing care.

Method

Patients attending the treatment programme at the 'Hospital 12 de Octubre' were randomized into two groups. In Group A (n = 123), patients received the usual treatment included in our programme, whereas in Group B (n = 126), patients also attended self-help groups. Patients were assessed with psychological scales at baseline, at the end of the treatment period and after completing the continuing care visits. Data were collected over a total of 6 years.

Results

During the treatment period, patients in Group B accumulated more months of abstinence and dropped out less. During continuing care, patients in Group B accumulated more months of abstinence and therapeutic adherence was higher. Variables that were associated with these results during the continuing care period were: visits to the GP, scores on anxiety, impulsivity and meaning of life scales, and belonging to the group that attended the alcoholic associations.

Conclusions

Mutual help groups incorporated into a public treatment programme appear to improve outcomes during treatment and on into continuing care. This experience supports cooperation between public health centres and alcoholic associations in treating alcoholism.

Short Summary

Including alcoholic associations into the public treatment programme for alcoholism of the 'Hospital 12 de Octubre' in Madrid was shown to be associated with better outcomes in terms of months of accumulated abstinence, dropout rates and therapeutic adherence, during the treatment and continuing care periods.