Organize and mobilize for implementation effectiveness to improve overdose education and naloxone distribution from syringe services programs: a randomized controlled trial

BACKGROUND

The United States (US) continues to face decades-long increases in opioid overdose fatalities. As an opioid overdose reversal medication, naloxone can dramatically reduce opioid overdose mortality rates when distributed to people likely to experience or witness an opioid overdose and packaged with education on its use, known as overdose education and naloxone distribution (OEND). Syringe services programs (SSPs) are ideal venues for OEND with staff who are culturally competent in providing services for people who are at risk of experiencing or observing an opioid overdose. We carried out a randomized controlled trial of SSPs to understand the effectiveness of the organize and mobilize for implementation effectiveness (OMIE) approach at improving OEND implementation effectiveness within SSPs.

METHODS

Using simple randomization, 105 SSPs were enrolled into the trial and assigned to one of two study arms - (1) dissemination of OEND best practice recommendations (Control SSPs) or the OMIE approach along with dissemination of the OEND best practice recommendations (i.e., OMIE SSPs). OMIE SSPs could participate in 60-min OMIE sessions once a month for up to 12 months. At 12-month post-baseline, 102 of 105 SSPs (97%) responded to the follow-up survey.

RESULTS

The median number of sessions completed by OMIE SSPs was 10. Comparing OMIE SSPs to control SSPs, we observed significant increases in the number of participants receiving naloxone (incidence rate ratio: 2.15; 95% CI: 1.42, 3.25; p < 0.01) and the rate of naloxone doses distributed per SSP participant (adjusted incidence rate ratio: 1.97; 95% CI: 1.18, 3.30; p = 0.01). We observed no statistically significant difference in the number of adopted best practices between conditions (difference in means 0.2, 95% CI: - 0.7, 1.0; p = 0.68). We also observed a threshold effect where SSPs receiving a higher OMIE dose had greater effect sizes with regard to the number of people given naloxone and the number of naloxone doses distributed.

CONCLUSIONS

In conclusion, the multifaceted OMIE approach was effective at increasing naloxone distribution from SSPs, despite substantial external shocks during the trial. These findings have major implications for addressing the overdose crisis, which has continued unabated for decades.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03924505 . Registered 19 April 2019.

Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a cluster-randomized type 3 hybrid trial

Background

Substance use disorders (SUDs) have a serious adverse impact on people living with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the "alter incentive/allowance structures" strategy.

Methods

Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined.

Results

The addition of P4P had a large and significant effect on the number of MIBIs implemented (d=1.30, p<.05) and reduction in anxiety (d=-1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality (d=1.24) and MIBI implementation effectiveness (d=1.28), but these were not significant (p<.10).

Conclusions

P4P is a form of the "alter incentive/allowance structures" strategy Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the cost-effectiveness of this strategy, as well as to examine the effectiveness of P4P to improve the implementation of other evidence-based innovations.

Trial registration

ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.

Effective, but underused: lessons learned implementing contingency management in real-world practice settings in the United States

Despite being one of the most effective adjunctive behavioral interventions in combination with medication for opioid use disorder, contingency management (CM) is one of the least available interventions in opioid treatment programs. This paradoxical state of affairs is perhaps the greatest example of the research-to-practice gap in the behavioral health field. Implementation science, a discipline that aims to identify replicable methods that can be used across settings and populations to bridge the gap between research and practice, can potentially help. Based on our team's experience implementing CM in opioid treatment programs, we detail five key lessons for researchers, clinicians, policy makers, and others seeking to implement and sustain CM in real-world settings. First, multiple barriers to CM implementation exist at both the counselor- and organization-levels, requiring multi-level solutions. Second, one-shot CM training alone is not sufficient for successful implementation: ongoing support is essential to achieve levels of intervention fidelity that will benefit patients. Third, assessing an organization's capacity for implementation prior to support provision can prevent costly mistakes. Fourth, implementors should plan for high staff turnover rates and expect the unexpected by developing detailed contingency plans. Finally, implementors should remember that the goal is to implement evidence-based CM and not simply incentives. We encourage colleagues to consider these lessons to increase the likelihood that CM can be implemented and sustained in a manner that improves the quality of care in opioid treatment programs.

Implementing contingency management for stimulant use in opioid treatment programs: protocol of a type III hybrid effectiveness-stepped-wedge trial

BACKGROUND

Contingency management (CM) is an evidence-based intervention for stimulant use and is highly effective in combination with medication for opioid use disorder. Yet, uptake of CM in opioid treatment programs that provide medication for opioid use disorder remains low. This paradox in which CM is one of the most effective interventions, yet one of the least available, represents one of the greatest research-to-practice gaps in the addiction health services field. Multi-level implementation strategies are needed to address barriers to CM implementation at both the provider- and organization-level. This type III hybrid effectiveness-implementation trial was funded by the National Institute on Drug Abuse to evaluate whether a multi-level implementation strategy, the Science of Service Laboratory (SSL), can effectively promote CM implementation in opioid treatment programs. Specific aims will test the effectiveness of the SSL on implementation outcomes (primary aim) and patient outcomes (secondary aim), as well as test putative mediators of implementation outcomes (exploratory aim).

METHODS

Utilizing a fully powered type III hybrid effectiveness-implementation trial with a stepped wedge design, we propose to randomize a cohort of 10 opioid treatment programs to receive the SSL across four steps. Each step, an additional 2-3 opioid treatment programs will receive the SSL implementation strategy, which has three core components: didactic training, performance feedback, and external facilitation. At six intervals, each of the 10 opioid treatment programs will provide de-identified electronic medical record data from all available patient charts on CM delivery and patient outcomes. Staff from each opioid treatment program will provide feedback on contextual determinants influencing implementation at three timepoints.

DISCUSSION

Between planning of this protocol and receipt of funding, the landscape for CM in the USA changed dramatically, with multiple Departments of Health launching state-wide CM initiatives. We therefore accelerated the protocol timeline and offered some cursory training resources to all sites as a preparation activity. We also began partnering with multiple Departments of Health to evaluate their rollout of CM using the measures outlined in this protocol.

TRIAL REGISTRATION

This study protocol is registered via ClinicalTrials.gov Identifier: NCT05702021. Date of registration: January 27, 2023.

Early COVID-Related pandemic impacts and subsequent opioid outcomes among persons receiving medication for opioid use disorder: a secondary data analysis of a Type-3 hybrid trial

BACKGROUND

Opioid overdoses have continued to increase since the start of the COVID-19 pandemic. The pathways through which the COVID-19 pandemic has affected trajectories of opioid use and opioid-related problems are largely unknown. Using the Epidemic-Pandemic Impacts Inventory (EPII), a novel instrument that assess pandemic-related impacts across multiple life domains, we tested the hypothesis that COVID-related impacts (on e.g., interpersonal conflict, employment, infection exposure, and emotional health) experienced in the early months of the pandemic would predict changes in opioid use and opioid-related problems at follow-up.

METHODS

This analysis was embedded within a cluster randomized type 3 implementation-effectiveness hybrid trial that had enrolled 188 patients across eight opioid treatments prior to the start of the pandemic. Participants had all been recently inducted on medication for opioid use disorder and were actively receiving treatment. Participants reported on their opioid use and opioid-related problems at baseline and 3-, 6-, and 9-month post-baseline assessments. Between May and August 2020, participants were sent an optional invitation to complete the EPII.

RESULTS

One hundred thirty-three respondents completed the EPII and 129 had sufficient data to analyze the EPII and at least one subsequent follow-up. In logistic and zero-inflated negative binomial analyses adjusting for covariates, each endorsed pandemic impact in the interpersonal conflict domain was associated with 67% increased odds of endorsement of any opioid use, and each impact in the employment and infection exposure-domains was associated with 25% and 75% increases in number of endorsed opioid-related problems, respectively.

CONCLUSIONS

Mitigating the effect of the pandemic on patients' interpersonal relationships and employment, and promoting greater infection control in opioid treatment programs, could be protective against negative opioid-related outcomes. Trial registration The present study describes secondary data analysis on a previously registered clinical trial: clinicaltrials.gov/ct2/show/NCT03931174.

Examining Changes in Pain Interference via Pandemic-Induced Isolation Among Patients Receiving Medication for Opioid Use Disorder: A Secondary Data Analysis

Background

Early in the pandemic, the United States population experienced a sharp rise in the prevalence rates of opioid use, social isolation, and pain interference. Given the high rates of pain reported by patients on medication for opioid use disorder (MOUD), the pandemic presented a unique opportunity to disentangle the relationship between opioid use, pain, and social isolation in this high-risk population. We tested the hypothesis that pandemic-induced isolation would partially mediate change in pain interference levels experienced by patients on MOUD, even when controlling for baseline opioid use. Such work can inform the development of targeted interventions for a vulnerable, underserved population.

Methods

Analyses used data from a cluster randomized trial (N = 188) of patients on MOUD across eight opioid treatment programs. As part of the parent trial, participants provided pre-pandemic data on pain interference, opioid use, and socio-demographic variables. Research staff re-contacted participants between May and June 2020 and 133 participants (71% response rate) consented to complete a supplemental survey that assessed pandemic-induced isolation. Participants then completed a follow-up interview during the pandemic that again assessed pain interference and opioid use. A path model assessed whether pre-pandemic pain interference had an indirect effect on pain interference during the pandemic via pandemic-induced isolation.

Results

Consistent with hypotheses, we found evidence that pandemic-induced isolation partially mediated change in pain interference levels among MOUD patients during the pandemic. Higher levels of pre-pandemic pain interference and opioid use were both significantly associated with higher levels of pandemic-induced isolation. In addition, pre-pandemic pain interference was significantly related to levels of pain interference during the pandemic, and these pain levels were partially explained by the level of pandemic-induced isolation reported.

Conclusions

Patients on MOUD with higher use of opioids and higher rates of pain pre-pandemic were more likely to report feeling isolated during COVID-related social distancing and this, in turn, partially explained changes in levels of pain interference. These results highlight social isolation as a key risk factor for patients on MOUD and suggest that interventions promoting social connection could be associated with reduced pain interference, which in turn could improve patient quality of life.

From innovative applications of the effectiveness-implementation hybrid trial design to the dissemination, implementation, effectiveness, sustainment, economics, and level-of-scaling hybrid trial design

To address the enduring gap between research and practice, there is a need to improve the speed and efficiency of research across the translational research spectrum. In 2012, the effectiveness-implementation hybrid trial design (HTD) was codified as a design with the potential to improve the speed and efficiency of translation, especially as part of T2 (clinical research) translational research. Building on this and other recent efforts to stimulate greater use of this novel HTD, the current article highlights an innovative application of each effectiveness-implementation HTD type. The completed application of the Type 1 effectiveness-implementation HTD tested the effectiveness of a clinical intervention for reducing HIV viral load and retaining people with HIV in care, as well as conducted a longitudinal mixed-methods examination to test for significant changes over time in three key measures of context, and economic evaluation of the clinical intervention. The completed application of the Type 2 effectiveness-implementation HTD used a dual-randomized design to simultaneously test the effectiveness of a clinical intervention for addressing substance use disorder among people with HIV and effectiveness of a blended strategy called the Implementation and Sustainment Facilitation (ISF) Strategy. This Type 2 hybrid trial was also innovative due to its focus on both sustainment and economic outcomes. The innovative Type 3 application (funded in 2008 and completed in 2012) tested the effectiveness and cost-effectiveness of using pay-for-performance to improve both implementation outcomes and client outcomes. This article also codifies a HTD called the Dissemination, Implementation, effectiveness, Sustainment, Economics, and Level-of-scaling (DIeSEL) HTD.

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.

A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial

BACKGROUND

Positive Health Check is an evidence-based video doctor intervention developed for improving the medication adherence, retention in care, and viral load suppression of people with HIV receiving clinical care.

SETTING

Four HIV primary care clinics within the United States.

METHODS

As part of a type 1 hybrid trial, a mixed-methods approach was used to longitudinally assess the following 3 key implementation constructs over a 23-month period: innovation-values fit (ie, the extent to which staff perceive innovation use will foster the fulfillment of their values), organizational readiness for change (ie, the extent to which organizational members are psychologically and behaviorally prepared to implement organizational change), and implementation climate (ie, the extent to which implementation is expected, supported, and rewarded). Quantitative mixed-effects regression analyses were conducted to assess changes over time in these constructs. Qualitative analyses were integrated to help provide validation and understanding.

RESULTS

Innovation-values fit and organizational readiness for change were found to be high and relatively stable. However, significant curvilinear change over time was found for implementation climate. Based on the qualitative data, implementation climate declined toward the end of implementation because of decreased engagement from clinic champions and differences in priorities between research and clinic staff.

CONCLUSIONS

The Positive Health Check intervention was found to fit within HIV primary care service settings, but there were some logistical challenges that needed to be addressed. Additionally, even within the context of an effectiveness trial, significant and nonlinear change in implementation climate should be expected over time.

Effectiveness of an Interactive, Highly Tailored "Video Doctor" Intervention to Suppress Viral Load and Retain Patients With HIV in Clinical Care: A Randomized Clinical Trial

BACKGROUND

To determine whether Positive Health Check, a highly tailored video doctor intervention, can improve viral suppression and retention in care.

SETTING

Four clinics that deliver HIV primary care.

METHODS

A hybrid type 1 effectiveness-implementation randomized trial design was used to test study hypotheses. Participants (N = 799) who were not virally suppressed, were new to care, or had fallen out of care were randomly assigned to receive Positive Health Check or the standard of care alone. The primary endpoint was viral load suppression, and the secondary endpoint was retention in care, both assessed at 12 months, using an intention-to-treat approach. A priori subgroup analyses based on sex assigned at birth and race were examined as well.

RESULTS

There were no statistically significant differences between Positive Health Check (N = 397) and standard of care (N = 402) for either endpoint. However, statistically significant group differences were identified from a priori subgroup analyses. Male participants receiving Positive Health Check were more likely to achieve suppression at 12 months than male participants receiving standard of care adjusted risk ratio [aRR] [95% confidence interval (CI)] = 1.14 (1.00 to 1.29), P = 0.046}. For retention in care, there was a statistically significant lower risk for a 6-month visit gap in the Positive Health Check arm for the youngest participants, 18-29 years old [aRR (95% CI) = 0.55 (0.33 to 0.92), P = 0.024] and the oldest participants, 60-81 years old [aRR (95% CI) = 0.49 (0.30 to 0.81), P = 0.006].

CONCLUSIONS

Positive Health Check may help male participants with HIV achieve viral suppression, and younger and older patients consistently attend HIV care.

REGISTRY NAME

Positive Health Check Evaluation Trial. Trial ID: 1U18PS004967-01. URL: https://clinicaltrials.gov/ct2/show/NCT03292913.

The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study

BACKGROUND

Given substance use disorders (SUDs) among people with HIV are highly prevalent, integrating SUD services within HIV service settings is needed to help end the HIV epidemic. In this study, we assessed the setting-intervention fit (SIF) of 9 evidence-based SUD interventions: acamprosate, disulfiram, oral naltrexone, injectable naltrexone, oral buprenorphine, injectable buprenorphine, contingency management, motivational interviewing, and cognitive behavioral therapy (CBT).

SETTING

Clinical and nonclinical HIV service organizations (HSOs) in the United States.

METHODS

In May 2020, a stakeholder-engaged real-time Delphi was completed with 202 HSOs. HSO respondents rated the extent to which each SUD intervention was fundable, implementable, retainable, sustainable, scalable, and timely for their HSO, and these 6 items were summed into an SIF score (possible range of 0-18).

RESULTS

Motivational interviewing had the highest average SIF score (11.42), with SIF scores above the midpoint (9.5) for clinical (11.51) and nonclinical HSOs (11.36). For nonclinical HSOs, none of the other interventions were above the midpoint. For clinical HSOs, the average SIF scores were above the midpoint for CBT (10.97) and oral buprenorphine (9.51). Multivariate regression analyses, which controlled for characteristics of the HSO respondent, revealed geographic region of the United States and whether the HSO currently offered any substance use services as 2 of the best predictors of SIF scores.

CONCLUSIONS

Notwithstanding the need to improve the SIF for the other evidence-based SUD interventions, motivational interviewing, CBT, and oral buprenorphine are currently the evidence-based SUD interventions with greatest perceived fit for integration within HSOs in the United States.

The implementation & sustainment facilitation (ISF) strategy: Cost and cost-effectiveness results from a 39-site cluster randomized trial integrating substance use services in community-based HIV service organizations

Background: As part of the Substance Abuse Treatment to HIV Care Project, the Implementation & Sustainment Facilitation (ISF) strategy was found to be an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for substance use disorders. This study presents the cost and cost-effectiveness results. Methods: Thirty-nine HIV service organizations were randomized to receive the ATTC-only condition or the ATTC + ISF condition. Two staff from each organization received the ATTC-training. In ATTC + ISF organizations, the same two staff and additional support staff participated in facilitation sessions to support MIBI implementation. We estimated costs using primary data on the time spent in each strategy and the time spent delivering 409 MIBIs to clients. We estimated staff-level cost-effectiveness for the number of MIBIs delivered, average MIBI quality scores, and total client days abstinent per staff. We used sensitivity analyses to test how changes to key variables affect the results. Results: Adjusted per-staff costs were $2,915 for the ATTC strategy and $5,371 for ATTC + ISF, resulting in an incremental cost of $2,457. ATTC + ISF significantly increased the number of MIBIs delivered (3.73) and the average MIBI quality score (61.45), yielding incremental cost effectiveness ratios (ICERs) of $659 and $40. Client days abstinent increased by 59 days per staff with a quality-adjusted life-year ICER of $40,578 (95% confidence interval $29,795–$61,031). Conclusions: From the perspective of federal policymakers, ISF as an adjunct to the ATTC strategy may be cost-effective for improving the integration of MIBIs within HIV service organizations, especially if scaled up to reach more clients. Travel accounted for nearly half of costs, and virtual implementation may further increase value. We also highlight two considerations for cost-effectiveness analysis with hybrid trials: study protocols kept recruitment low and modeling choices affect how we interpret the effects on client-level outcomes.

The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.

A peek behind the curtain: exploring coaching styles within the implementation and sustainment facilitation (ISF) strategy in the substance abuse treatment to HIV care study

BACKGROUND

The Grasha-Riechmann teaching styles, which includes three didactic and two prescriptive styles, have been shown to help enhance learning within educational settings. Although an adaption of the Grasha-Riechmann style classification has enabled coaching styles to be identified for use as part of quality improvement (QI) initiatives, research has not examined the styles actually utilized by coaches within a QI initiative or how the styles change overtime when the coach is guiding an organization through change implementation. Interactions between coaches and HIV service organization (HSO) staff participating in a large implementation research experiment called the Substance Abuse Treatment to HIV care (SAT2HIV) Project were evaluated to begin building an evidence base to address this gap in implementation research.

METHODS

Implementation & Sustainment Facilitation (ISF) Strategy meetings (n = 137) between coaches and HSO staff were recorded and professionally transcribed. Thematic coding classifications were developed from the Grasha-Riechmann framework and applied to a purposively selected sample of transcripts (n = 66). Four coders independently coded transcripts using NVivo to facilitate text identification, organization, and retrieval for analysis. Coaching style use and changes across the three ISF phases were explored.

RESULTS

Facilitator and formal authority were the two coaching styles predominately used. Facilitator sub-themes shifted from asking questions and providing support to supporting independent action over time. Coaches' use of formal authority sub-styles shifted notably across time from setting expectations or ensuring preparation to offering affirmation or feedback about changes that the HSO's were implementing. The use of the delegator or personal model coaching styles occurred infrequently.

CONCLUSIONS

The current research extends implementation research's understanding of coaching. More specifically, findings indicate it is feasible to use the Grasha-Riechmann framework to qualitatively identify coaching styles utilized in a facilitation-based implementation strategy. More importantly, results provide insights into how different coaching styles were utilized to implement an evidence-based practice. Further research is needed to examine how coaching styles differ by organization, impact implementation fidelity, and influence both implementation outcomes and client outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02495402 . Registered on July 6, 2015.

Sustainment of Contingency Management within Opioid Treatment Programs: COVID-Related Barriers and Innovative Workflow Adaptations

Introduction

Contingency Management (CM) is one of the most effective interventions for persons with opioid use disorder, but one of the least available interventions in community settings, including opioid treatment programs. Project MIMIC is a NIDA-funded cluster randomized trial that is measuring CM implementation and sustainment across 30 opioid treatment programs in the New England region of the United States. The advent of the COVID-19 pandemic occurred in the midst of Project MIMIC's first cohort of eight opioid treatment programs, presenting a natural opportunity to document and analyze novel challenges to CM sustainment. Utilizing both quantitative and qualitative data collection, we aimed to identify both COVID-related barriers to CM sustainment and innovative workflow strategies to mitigate these barriers.

Methods

Quantitative analysis was conducted using data collected from a study-specific CM tracker tool on various CM implementation metrics over three distinct, successive time intervals: prior to COVID-19 social distancing orders with active support; during COVID-19 social distancing orders with active support; and during COVID-19 social distancing orders after removal of support. Semi-structured qualitative interviews were conducted with a representative from each of the eight opioid treatment programs. Using a reflexive team approach, transcripts were coded by independent raters to identify both COVID-related barriers to sustainment and innovative workflow adaptations.

Results

Quantitative data revealed a substantial decrease in the number of CM encounters following social distancing orders from 31.8 encounters weekly across eight programs to 6.9 encounters weekly across five programs. A further decline to 1.8 weekly encounters across three programs was observed after implementation support was removed. Four COVID-related barriers were identified via thematic analysis: fear of contagion; difficulty engaging patients remotely; challenges re-defining the CM attendance target due to changing regulations; and staff shortages. Potential adjustments discussed to help address one or more of these barriers included an electronic prize generator; use of technology to promote engagement; brief individual remote check-ins; and expansion of training to non-counseling staff.

Conclusion

Although CM implementation challenges emerged during the pandemic, associated workflow adaptations also emerged. The feedback solicited in this study will inform multi-level strategies to aid with CM sustainment post-pandemic.

Persons from racial and ethnic minority groups receiving medication for opioid use disorder experienced increased difficulty accessing harm reduction services during COVID-19

Introduction

The COVID-19 pandemic collided with the opioid epidemic and longstanding health inequities to exacerbate the disproportionate harms experienced by persons with opioid use disorder (OUD) who self-identify as from racial and ethnic minority groups. Disrupted access to harm reduction services (e.g., naloxone, sterile syringes, recovery support) is one pathway whereby COVID-19 might exacerbate health disparities. We tested the hypothesis that persons receiving medication for opioid use disorder (MOUD) who self-identify as from racial/ethnic minority groups would experience more disruptions in access to harm reduction services than persons identifying as non-Hispanic White, even when controlling for severity of opioid use and sociodemographics (e.g., education, income, biological sex, age).

Methods

Analyses used data from a cluster randomized trial that had enrolled 188 patients, all of whom had provided baseline data on sociodemographics and severity of opioid use, across eight opioid treatment programs. Data collectors re-contacted participants between May and June 2020 and 133 (71% response rate) agreed to complete a survey about access to harm reduction services.

Results

Twenty-six respondents (20%) identified as from racial/ethnic minority groups (predominantly Black, Hispanic, and/or biracial). Between 7% and 27% of respondents reported disrupted access to harm reduction services. Logistic regressions indicated that persons identifying as from racial/ethnic minority groups were 8–10 times more likely than persons identifying as non-Hispanic White to report reduced access to naloxone and sterile syringes (p < .01), even when accounting for potential confounding variables.

Conclusions

This report concludes with a discussion of potential outreach strategies and policies to advance more equitable access to essential harm reduction services.

Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial

BACKGROUND

Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim).

METHODS

A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff's extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff's intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline).

DISCUSSION

There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators.

TRIAL REGISTRATION

This clinical trial has been registered with clinicaltrials.gov (NCT03931174). Registered April 30, 2019. https://clinicaltrials.gov/ct2/show/NCT03931174?term=project+mimic&draw=2&rank=1.

Resilience-Focused HIV Care to Promote Psychological Well-Being During COVID-19 and Other Catastrophes

The COVID-19 pandemic has adversely affected people with HIV due to disruptions in prevention and care services, economic impacts, and social isolation. These stressors have contributed to worse physical health, HIV treatment outcomes, and psychological wellness. Psychological sequelae associated with COVID-19 threaten the overall well-being of people with HIV and efforts to end the HIV epidemic. Resilience is a known mediator of health disparities and can improve psychological wellness and behavioral health outcomes along the HIV Continuum of Care. Though resilience is often organically developed in individuals as a result of overcoming adversity, it may be fostered through multi-level internal and external resourcing (at psychological, interpersonal, spiritual, and community/neighborhood levels). In this Perspective, resilience-focused HIV care is defined as a model of care in which providers promote optimum health for people with HIV by facilitating multi-level resourcing to buffer the effects of adversity and foster well-being. Adoption of resilience-focused HIV care may help providers better promote well-being among people living with HIV during this time of increased psychological stress and help prepare systems of care for future catastrophes. Informed by the literature, we constructed a set of core principles and considerations for successful adoption and sustainability of resilience-focused HIV care. Our definition of resilience-focused HIV care marks a novel contribution to the knowledge base and responds to the call for a multidimensional definition of resilience as part of HIV research.

Implementation support for contingency management: preferences of opioid treatment program leaders and staff

BACKGROUND

Contingency management (CM), a behavioral intervention that provides incentives for achieving treatment goals, is an evidence-based adjunct to medication to treat opioid use disorder. Unfortunately, many front-line treatment providers do not utilize CM, likely due to contextual barriers that limit effective training and ongoing support for evidence-based practices. This study applied user-informed approaches to adapt a multi-level implementation strategy called the Science to Service Laboratory (SSL) to support CM implementation.

METHODS

Leaders and treatment providers working in community-based opioid treatment programs (OTPs; N = 43) completed qualitative interviews inquiring about their preferences for training and support implementation strategies (didactic training, performance feedback, and external facilitation). Our team coded interviews using a reflexive team approach to identify common a priori and emergent themes.

RESULTS

Leaders and providers expressed a preference for brief training that included case examples and research data, along with experiential learning strategies. They reported a desire for performance feedback from internal supervisors, patients, and clinical experts. Providers and leaders had mixed feelings about audio-recording sessions but were open to the use of rating sheets to evaluate CM performance. Finally, participants desired both on-call and regularly scheduled external facilitation to support their continued use of CM.

CONCLUSIONS

This study provides an exemplar of a user-informed approach to adapt the SSL implementation support strategies for CM scale-up in community OTPs. Study findings highlight the need for user-informed approaches to training, performance feedback, and facilitation to support sustained CM use in this setting.

Impacts of the COVID-19 pandemic on healthcare access among patients receiving medication for opioid use disorder

BACKGROUND

The COVID-19 pandemic significantly altered treatment delivery for opioid treatment programs (OTPs) dispensing medications for opioid use disorder (MOUD). We aimed to identify patterns of substance use among MOUD patients and examine whether COVID-19-related impacts on access to healthcare varied across subgroups.

METHODS

This analysis was embedded within a type 3 hybrid trial that enrolled patients across eight OTPs at the start of the pandemic. Enrolled patients reported on past-30 day use of multiple substances during their baseline assessment. Participants re-contacted in May-July 2020 completed a survey about COVID-19-related impacts on various life domains. Using latent class analysis we identified patient subgroups, and then examined group differences on a set of negative and positive COVID-19 impacts related to healthcare access.

RESULTS

Of the 188 trial participants, 135 (72 %) completed the survey. Latent class analysis identified three MOUD patient subgroups: minimal use (class probability: 0.25); opioid use (class probability: 0.34); and polysubstance use (class probability: 0.41). Compared to the minimal use group, the polysubstance use group reported increased substance use and difficulty accessing sterile needles, naloxone, and preferred substance. The opioid use group reported increased substance use and difficulty accessing their preferred substance. There were no significant group differences related to accessing routine or specialized healthcare or medication; or paying attention to their health.

CONCLUSIONS

During COVID-19, many MOUD patients reported challenges accessing care, particularly harm reduction services for patients with polysubstance use. Additional efforts, like providing wraparound support, may be necessary to serve the needs of MOUD patients.

Kentucky Women's Justice Community Opioid Innovation Network (JCOIN): A type 1 effectiveness-implementation hybrid trial to increase utilization of medications for opioid use disorder among justice-involved women

The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities.

Priority domains, aims, and testable hypotheses for implementation research: Protocol for a scoping review and evidence map

BACKGROUND

The challenge of implementing evidence-based innovations within practice settings is a significant public health issue that the field of implementation research (IR) is focused on addressing. Significant amounts of funding, time, and effort have been invested in IR to date, yet there remains significant room for advancement, especially regarding IR's development of scientific theories as defined by the National Academy of Sciences (i.e., a comprehensive explanation of the relationship between variables that is supported by a vast body of evidence). Research priority setting (i.e., promoting consensus about areas where research effort will have wide benefits to society) is a key approach to helping accelerate research advancements. Thus, building upon existing IR, general principles of data reduction, and a general framework for moderated mediation, this article identifies four priority domains, three priority aims, and four testable hypotheses for IR, which we organize in the priority aims and testable hypotheses (PATH) diagram.

METHODS

The objective of this scoping review is to map the extent to which IR has examined the identified PATH priorities to date. Our sample will include IR published in leading implementation-focused journals (i.e., Implementation Science, Implementation Science Communications, and Implementation Research and Practice) between their inception and December 2020. The protocol for the current scoping review and evidence map has been developed in accordance with the approach developed by Arksey and O'Malley and advanced by Levac, Colquhoun, and O'Brien. Because scoping reviews seek to provide an overview of the identified evidence base rather than synthesize findings from across studies, we plan to use our data-charting form to provide a descriptive overview of implementation research to date and summarize the research via one or more summary tables. We will use the PATH diagram to organize a map of the evidence to date.

DISCUSSION

This scoping review and evidence map is intended to help accelerate IR focused on suggested priority aims and testable hypotheses, which in turn will accelerate IR's development of National Academy of Sciences-defined scientific theories and, subsequently, improvements in public health.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework https://osf.io/3vhuj/.

Model and approach for assessing implementation context and fidelity in the HEALing Communities Study

BACKGROUND

In response to the U.S. opioid epidemic, the HEALing (Helping to End Addiction Long-term^SM) Communities Study (HCS) is a multisite, wait-listed, community-level cluster-randomized trial that aims to test the novel Communities That HEAL (CTH) intervention, in 67 communities. CTH will expand an integrated set of evidence-based practices (EBPs) across health care, behavioral health, justice, and other community-based settings to reduce opioid overdose deaths. We present the rationale for and adaptation of the RE-AIM/PRISM framework and methodological approach used to capture the CTH implementation context and to evaluate implementation fidelity.

METHODS

HCS measures key domains of the internal and external CTH implementation context with repeated annual surveys and qualitative interviews with community coalition members and key stakeholders. Core constructs of fidelity include dosage, adherence, quality, and program differentiation-the adaptation of the CTH intervention to fit each community's needs. Fidelity measures include a monthly CTH checklist, collation of artifacts produced during CTH activities, coalition and workgroup attendance, and coalition meeting minutes. Training and technical assistance delivered by the research sites to the communities are tracked monthly.

DISCUSSION

To help attenuate the nation's opioid epidemic, the adoption of EBPs must be increased in communities. The HCS represents one of the largest and most complex implementation research experiments yet conducted. Our systematic examination of implementation context and fidelity will significantly advance understanding of how to best evaluate community-level implementation of EBPs and assess relations among implementation context, fidelity, and intervention impact.

Is necessity also the mother of implementation? COVID-19 and the implementation of evidence-based treatments for opioid use disorders

Opioid-related overdoses and the coronavirus disease 2019 (COVID-19) represent two of the deadliest crises in United States' history and together constitute a syndemic. The intersecting risks of this syndemic underscore the urgent need to implement effective opioid use disorder (OUD) treatments that are sustainable amid COVID-19 mitigation strategies. In response to new federal guidance released during the pandemic, opioid treatment programs (OTPs) have quickly innovated to implement new systems of medication delivery. OTPs rapid implementation of new medication delivery models defies conventional wisdom about the pace of research transfer. As part of an ongoing cluster-randomized type 3 hybrid trial evaluating strategies to implement contingency management (CM), select staff of eight OTPs had been trained to deliver CM and were in the midst of receiving ongoing implementation support. As COVID-19 emerged, all eight OTPs mirrored trends in the addiction field and effectively adapted to federal/state demands to implement new methods of medication delivery. However, over the past few months, necessity has arguably been the mother of implementation. We have observed greater variance among these OTPs' success with the additional implementation of adjunctive CM. The speed and variability of innovation raises novel questions about drivers of implementation. We argue that the mother of the next innovation should be a public call for a progressive, thoughtful set of public health policies and other external setting levers to address the needs of those with OUD and the OTPs that serve them.

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Opioid-related overdoses and COVID-19 constitute a syndemic.

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Opioid treatment programs (OTPs) have rapidly innovated in response to COVID-19.

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OTPs have implemented new medication for opioid use disorder (MOUD) delivery models.

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OTPs have had variable success with sustaining adjunct behavioral interventions.

•

Speed and variability of innovation raises questions about implementation drivers.

The implementation and sustainment facilitation strategy improved implementation effectiveness and intervention effectiveness: Results from a cluster-randomized, type 2 hybrid trial

Background:

Substance use disorders (SUDs) among people with HIV are both prevalent and problematic. The Substance Abuse Treatment to HIV care project was funded to test the Implementation and Sustainment Facilitation (ISF) strategy as an adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for SUDs within HIV community-based organizations.

Methods:

Using a cluster-randomized, type 2 hybrid trial design, 39 HIV organizations were randomized to either (1) ATTC (n = 19) or (2) ATTC + ISF (n = 20). Each HIV organization identified two staff members to be prepared to implement the MIBI (N = 78). Subsequently, during the implementation phase, HIV organizations in each condition randomized client participants (N = 824) to one of the two intervention conditions: usual care (UC; n = 415) or UC + MIBI (n = 409). Both staff-level outcomes and client-level outcomes were examined.

Results:

The ISF strategy had a significant impact on the implementation effectiveness (i.e., the consistency and the quality of implementation; β = .65, p = .01) but not on time-to-proficiency (β = −.02) or level-of-sustainment (β = .09). In addition, the ISF strategy was found to have a significant impact on the intervention effectiveness (the effectiveness of the MIBI), at least in terms of significantly decreasing the odds (odds ratio = 0.11, p = .02) of clients using their primary substance daily during follow-up.

Conclusion:

The ISF strategy was found to be an effective adjunct to the ATTC strategy in terms of implementation effectiveness and intervention effectiveness. It is recommended that future efforts to integrate the project’s MIBI for SUD within HIV organizations use the ATTC + ISF strategy. However, given the ISF strategy did not have a significant impact on level-of-sustainment, implementation research testing the extent to which the ATTC + ISF strategy can be significantly enhanced through effective sustainment strategies is warranted.

Plain language abstract

Substance use among people living with HIV is associated with increased mental health problems, worse medication adherence, and worse HIV viral suppression. Increasing substance use-related services in HIV community-based organizations is an important public health need. The Substance Abuse Treatment to HIV care project tested two strategies for helping HIV organizations implement a brief intervention (BI) designed to motivate clients to decrease their substance use. The project also tested if receiving a BI improved clients’ outcome. Two staff from each of the 39 participating organizations were taught how to deliver the BI using the Addiction Technology Transfer Center (ATTC) training strategy (online and in-person training, monthly feedback, and coaching). Half of the organizations also received the Implementation and Sustainment Facilitation (ISF) strategy, which included monthly meetings with an ISF coach for the two BI staff and one or more leadership staff from the organization. Organizations that received both the ATTC and ISF strategies delivered more BIs and higher quality BIs than organizations that only received the ATTC strategy. In addition, clients receiving BIs at organizations that received both strategies were more likely to decrease their substance use. However, receiving both strategies did not improve how quickly staff learned to deliver the BI or improve the number of BIs delivered during the project’s 6-month sustainment phase. Future research focused on implementing BIs within HIV organizations should consider using the ATTC and ISF strategies while also seeking to enhance the strategies to improve sustainment.

Implementing Web-Based Interventions in HIV Primary Care Clinics: Pilot Implementation Evaluation of Positive Health Check

Background

Web-based interventions can help people living with HIV achieve better clinical outcomes and behaviors, but integrating them into clinical practice remains challenging. There is a gap in understanding the feasibility of implementing these interventions in HIV clinic settings from the clinicians’ perspective.

Objective

The goal of the research was to determine whether Positive Health Check (PHC)—a Web-based, tailored video counseling tool focused on increasing patient adherence and retention in care and reducing HIV risk among HIV-positive patients—was acceptable, appropriate, and feasible for HIV primary care clinic staff to implement in clinic workflows.

Methods

A multiple-case study design was used to evaluate the pilot implementation. Four primary care clinics located in the southeastern United States implemented PHC over a 1-month period. Nine clinic staff across the clinics participated in structured interviews before, during, and after the implementation. In total, 54 interviews were conducted. We used a framework analysis approach to code the data and identify themes related to implementation outcomes, including acceptability, appropriateness, and feasibility. We also analyzed patient intervention use metrics (n=104) to quantify patient intervention completion rates (n=68).

Results

Overall, clinicians viewed PHC as acceptable and appropriate. Themes that emerged related to these implementation outcomes include the ability for PHC to increase provider-patient communication and its ability to engage patients due to the tailored and interactive design. While generally feasible to implement, challenges to the clinic workflow and physical environment were areas that clinics needed to manage to make PHC work in their clinics.

Conclusions

Findings from this pilot implementation suggest that clinical staff viewed PHC as acceptable and appropriate, especially as more patients used the intervention over the pilot period. Feasibility of implementation was challenging in some cases, and lessons learned from this pilot implementation can provide information for larger scale tests of the intervention that include assessment of both implementation outcomes and clinical outcomes.

The Temporal Relationship Between Medicaid Payment Acceptance and the Implementation of Medication-Assisted Drug Treatment

OBJECTIVE

To examine the temporal relationship of Medicaid funding on the implementation of evidence-based practices (EBPs) in outpatient substance use disorder (SUD) treatment.

METHODS

We examined data from 61 publicly funded SUD treatment programs in 2011 and 2013 using crossed-lagged regressions. We tested the impact of Medicaid payment acceptance on 2 measures of EBP implementation-contingency management treatment (CMT) and medication-assisted treatment (MAT).

RESULTS

Medicaid payment acceptance at wave 1 was not associated with implementation of CMT at wave 2 (standardized estimate = 0.170, SE = 0.208, P > .05). However, Medicaid payment acceptance at wave 1 was associated with implementation of MAT at wave 2 (standardized estimate = 0.880, SE = 0.047, P < .001).

CONCLUSIONS

Medicaid payment acceptance has a temporal relationship with the implementation of MAT in SUD treatment programs serving one of the largest racial/ethnic minority communities in the United States.

Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial

BACKGROUND

Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs).

METHODS

Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes.

RESULTS

At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191-$16,171).

CONCLUSION

This study provides experimental evidence supporting P4P as a cost-effective implementation strategy.

TRIAL REGISTRATION

NCT01016704 .

Correction to: Testing the effectiveness of a motivational interviewing-based brief intervention for substance use as an adjunct to usual care in community-based AIDS service organizations: study protocol for a multisite randomized controlled trial

Upon publication of the original article.

Testing the effectiveness of a motivational interviewing-based brief intervention for substance use as an adjunct to usual care in community-based AIDS service organizations: study protocol for a multisite randomized controlled trial

Background

In 2010, the first comprehensive National HIV/AIDS Strategy for the United States was released and included three goals: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and improving health outcomes for people living with HIV, and (3) reducing HIV-related health disparities and health inequities. In 2013, as part of its effort to help address the National HIV/AIDS Strategy, the National Institute on Drug Abuse (NIDA) funded a type 2 effectiveness-implementation hybrid trial titled the Substance Abuse Treatment to HIV Care (SAT2HIV) Project. Aim 1 of the SAT2HIV Project tests the effectiveness of a motivational interviewing-based brief intervention (MIBI) for substance use as an adjunct to usual care within AIDS Service Organizations (ASOs) as part of its MIBI Experiment. Aim 2 of the SAT2HIV Project tests the effectiveness of implementation and sustainment facilitation (ISF) as an adjunct to the Addiction Technology Transfer Center (ATTC) model for training staff in motivational interviewing as part of its ISF Experiment. The current paper describes the study protocol for the ISF Experiment.

Methods

As part of a multisite randomized controlled trial, individuals with comorbid HIV/AIDS and problematic substance use are randomized to receive either the ASOs’ usual care (control condition) or usual care plus a MIBI for substance use (experimental condition) delivered by trained ASO case-management staff. Primary outcome measures are reductions in days of primary substance use, number of substance-related problems, times engaging in risky behaviors, days of non-adherence to HIV medications, and increases in substance use treatment. As part of this paper, we describe the trial protocol in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines.

Discussion

If successfully able to implement MIBI as an effective adjunct to usual care, the current trial may have a significant impact on increasing the capacity of ASOs to address problematic substance use among individuals living with HIV/AIDS. Reducing the prevalence of problematic substance use among individuals living with HIV/AIDS within the United States may lead to significant improvements on key performance measures (i.e., the HIV Care Continuum and the 90-90-90 target).

Trial registration ClinicalTrials.gov: NCT02495402

Electronic supplementary material

The online version of this article (10.1186/s13722-017-0095-8) contains supplementary material, which is available to authorized users.

Testing the implementation and sustainment facilitation (ISF) strategy as an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy: study protocol for a cluster randomized trial

BACKGROUND

Improving the extent to which evidence-based practices (EBPs)-treatments that have been empirically shown to be efficacious or effective-are integrated within routine practice is a well-documented challenge across numerous areas of health. In 2014, the National Institute on Drug Abuse funded a type 2 effectiveness-implementation hybrid trial titled the substance abuse treatment to HIV Care (SAT2HIV) Project. Aim 1 of the SAT2HIV Project tests the effectiveness of a motivational interviewing-based brief intervention (MIBI) for substance use as an adjunct to usual care within AIDS service organizations (ASOs) as part of its MIBI Experiment. Aim 2 of the SAT2HIV Project tests the effectiveness of implementation and sustainment facilitation (ISF) as an adjunct to the Addiction Technology Transfer Center (ATTC) model for training staff in motivational interviewing as part of its ISF Experiment. The current paper describes the study protocol for the ISF Experiment.

METHODS

Using a cluster randomized design, case management and leadership staff from 39 ASOs across the United States were randomized to receive either the ATTC strategy (control condition) or the ATTC + ISF strategy (experimental condition). The ATTC strategy is staff-focused and includes 10 discrete strategies (e.g., provide centralized technical assistance, conduct educational meetings, provide ongoing consultation). The ISF strategy is organization-focused and includes seven discrete strategies (e.g., use an implementation advisor, organize implementation team meetings, conduct cyclical small tests of change). Building upon the exploration-preparation-implementation-sustainment (EPIS) framework, the effectiveness of the ISF strategy is examined via three staff-level measures: (1) time-to-proficiency (i.e., preparation phase outcome), (2) implementation effectiveness (i.e., implementation phase outcome), and (3) level of sustainment (i.e., sustainment phase outcome).

DISCUSSION

Although not without limitations, the ISF experiment has several strengths: a highly rigorous design (randomized, hypothesis-driven), high-need setting (ASOs), large sample size (39 ASOs), large geographic representation (23 states and the District of Columbia), and testing along multiple phases of the EPIS continuum (preparation, implementation, and sustainment). Thus, study findings will significantly improve generalizable knowledge regarding the best preparation, implementation, and sustainment strategies for advancing EBPs along the EPIS continuum. Moreover, increasing ASO's capacity to address substance use may improve the HIV Care Continuum. Trial registration ClinicalTrials.gov: NCT03120598.

Measuring sustainment of an evidence based treatment for adolescent substance use

BACKGROUND

Measuring the extent a behavioral treatment is sustained in usual care practice settings after initial support for implementation ends is challenging. Oftentimes dichotomous self-report measures are used to measure health program sustainment, but these measures may not adequately capture the quality or extent of behavioral treatment delivery. Using data collected from community based organizations that received support to implement the Adolescent Community Reinforcement Approach (A-CRA), a measure of the extent of sustainment was derived.

METHODS

Based on implementation theories and implementation support protocols, a total of 10 core treatment elements were identified to measure the extent of sustainment using information collected from key clinical staff. Item response theory (IRT) and principal component analyses (PCA) were used to further refine the 10 elements into composite measures of sustainment. The association between the 10 elements and the relationships between the comprehensive measures to a dichotomous sustainment measure were also examined.

RESULTS

Results from PCA identified two components from the initial 10 elements for measuring the extent of A-CRA treatment sustainment. The two components described different aspects of organizational support for A-CRA treatment implementation, one representing the quality or extent of treatment staffing and delivery and the other representing the quality of or extent of clinical supervision.

CONCLUSIONS

Using IRT and PCA, we were able to derive components that could be used to measure the extent of EBT sustainment and also better capture the quality of treatment delivery than the use of simple dichotomous measure. The methodological contribution of our study is that we have demonstrated a general analytic approach that may be applicable for other psychosocial treatments.

Factors associated with an evidence-based measure of implementation for the Adolescent Community Reinforcement Approach

BACKGROUND

An evidence-based measure of implementation (EBMI) is an implementation outcome measure shown to have predictive validity with one or more future-measured constructs of importance. The current study sought to identify correlates and predictors of an EBMI called procedure exposure. Garner et al. (2016) found procedure exposure to be an EBMI for the Adolescent Community Reinforcement Approach (A-CRA).

METHODS

The dataset included 76 community-based substance use treatment organizations located across the United States. Organizational-level regression analyses, which were framed within the context of Chaudoir et al. (2013) framework for predicting implementation outcomes, were used to examine predictors of A-CRA procedure exposure RESULTS: The Washington Circle's treatment initiation performance measure (B=5.05 [SE=1.60], p=0.002), as well as session exposure (B=0.18 [SE=0.06], p=0.003), were significant predictors of A-CRA procedure exposure in the backward stepwise regression analysis (Adjusted R-square=0.55). The Washington Circle's treatment engagement performance measure (B=7.93 [SE=0.77], p<0.001), as well as time-to-proficiency (B=-0.04 [SE=0.02], p=0.02), each had significant bivariate relationships with A-CRA procedure exposure but were not retained in the final model.

CONCLUSIONS

Organizations implementing A-CRA are encouraged to make the following high priorities: (a) scheduling and completing a subsequent treatment session within 14days of their index session (treatment initiation) and (b) providing a targeted number of treatment sessions to each client (session exposure). To the extent organizations do this, they may be more likely to achieve higher levels of A-CRA procedure exposure.

Does the implementation of evidence-based and culturally competent practices reduce disparities in addiction treatment outcomes?

RATIONALE

Research is limited on the extent to which implementation of evidence-based and culturally responsive practices reduces outcome disparities in substance use disorder treatment. We examined the role of contingency management treatment (CMT), medication-assisted treatment (MAT), and culturally competent practices on Mexican Americans' rate of successful completion of treatment.

METHODS

We analyzed a concatenated dataset from 153 publicly funded substance use disorder treatment programs in Los Angeles County, California, in 2011 and 2013. These data were merged with data from 15,412 adult clients in both periods, of whom we selected only Mexican Americans (46.3%) and non-Latino Whites (53.7%). The outcome was successful treatment completion. The main independent variables were client demographics, drug use severity, mental health issues, and program license and professional accreditation.

RESULTS

Less than half of the programs highly implemented CMT, MAT, and culturally competent practices. CMT and cultural competence were not associated with successful treatment completion. However, Mexican Americans in programs with high degree of implementation of MAT had higher odds of successfully completing treatment compared to non-Latino Whites and programs with low MAT (OR=1.389; 95% CI=1.018, 1.897).

CONCLUSIONS

Findings highlight the role of MAT in reducing the disparity in treatment completion between Mexican Americans and non-Latino Whites. Implications for health policy and the dissemination of MAT are discussed.

Predicting evidence-based treatment sustainment: results from a longitudinal study of the Adolescent-Community Reinforcement Approach

BACKGROUND

Implementation support models are increasingly being used to enhance the delivery of evidence-based treatments (EBTs) in routine care settings. Little is known about the extent to which these models lead to continued EBT use after implementation support ends. Moreover, few empirical studies longitudinally examine the hypothesized factors associated with long-term psychosocial EBT use (i.e., sustainment). In an effort to address this gap, the current study examined sustainment of an EBT called the Adolescent-Community Reinforcement Approach (A-CRA) following the end of implementation support.

METHODS

Between 2006 and 2010, the Substance Abuse and Mental Health Services Administration awarded 3 years of A-CRA implementation support to 82 community-based organizations around the USA. The extent to which A-CRA was sustained following grant end and the hypothesized factors associated with EBT sustainment were collected using both retrospective and prospective data. We examined the extent to which 10 core treatment elements of A-CRA were sustained and the associations between the extent of A-CRA sustainment and hypothesized factors using a pattern-mixture longitudinal modeling approach.

RESULTS

Staff from 76 organizations participated in data collection for a 92.86% response rate. On average, about half of the 10 core treatment elements were sustained following the loss of implementation support. Factors that appeared most important to A-CRA sustainment included characteristics that were related to the outer setting (communication, funding, and partnerships), inner setting (political support, organizational capacity, and supervisor turnover rate), implementation support period (number of clinicians and supervisors certified and employed at support end and number of youth served), and staff perceptions of the intervention (implementation difficulty, relative advantage, and perceived success).

CONCLUSIONS

Even with multiple years of implementation support, community-based organizations face challenges in sustaining EBT delivery over time. Consistent with implementation theories, multiple factors appear related with EBT sustainment, including the degree of implementation during the initial support period, as well as adequate funding, infrastructure support, and staff support following the end of funding.

Identifying and reducing disparities in successful addiction treatment completion: testing the role of Medicaid payment acceptance

BACKGROUND

Medicaid has become the largest payer of substance use disorder treatment and may enhance access to quality care and reduce disparities. We tested whether treatment programs' acceptance of Medicaid payments was associated with reduced disparities between Mexican Americans and non-Latino Whites.

METHODS

We analyzed client and program data from 122 publicly funded treatment programs in 2010 and 112 programs in 2013. These data were merged with information regarding 15,412 adult clients from both periods, of whom we selected only Mexican Americans (n = 7130, 46.3%) and non-Latino Whites (n = 8282, 53.7%). We used multilevel logistic regression and variance decomposition to examine associations and underlying factors associated with Mexican American and White differences in treatment completion. Variables of interest included client demographics; drug use severity and mental health issues; and program license, accreditation, and acceptance of Medicaid payments.

RESULTS

Mexican Americans had lower odds of treatment completion (OR = 0.677; 95% CI = 0.534, 0.859) compared to non-Latino Whites. This disparity was explained in part by primary drug used, greater drug use severity, history of mental health disorders, and program acceptance of Medicaid payments. The interaction between Mexican Americans and acceptance of Medicaid was statistically significant (OR = 1.284; 95% CI = 1.008, 1.637).

CONCLUSIONS

Findings highlighted key program and client drivers of this disparity and the promising role of program acceptance of Medicaid payment to eliminate disparities in treatment completion among Mexican Americans. Implications for health policy during the Trump Administration are discussed.

Toward Evidence-Based Measures of Implementation: Examining the Relationship Between Implementation Outcomes and Client Outcomes

BACKGROUND

Developing consistent, valid, and efficient implementation outcome measures is necessary to advance implementation science. However, development of such measures has been limited to date, especially for validating the extent to which such measures are associated with important improvements in client outcomes. This study seeks to address this gap by developing one or more evidence-based measures of implementation (EBMIs; i.e., implementation outcome measure that is predictive of improvements in key client outcomes) for the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based practice (EBP) for adolescent substance use.

METHODS

Data for the current study were collected as part of a large-scale federally funded EBP dissemination and implementation initiative. The multilevel dataset included 65 substance use treatment organizations, 308 clinicians, and 5873 adolescent clients. Adjusted multilevel regression analyses were used to examine the extent to which client-level outcome measures assessed at 6-month follow-up (i.e., substance use, emotional problems) could be predicted by four implementation outcomes: two measures of fidelity (i.e., session exposure, procedure exposure) and two measures of penetration (i.e., absolute client penetration, absolute staff penetration).

RESULTS

Adjusting for client substance use at intake, as well as several client characteristics (e.g., age, race, criminal justice involvement), client substance use at follow-up was significantly lower for treatment organizations that had higher procedure exposure (B=-1.227, standard error [SE]=0.583, 95% confidence interval=-2.370, 0.252; p<.05). None of the other three implementation outcome measures were found to predict improvements in client outcomes.

CONCLUSIONS

The current study provides support for procedure exposure as an organizational-level EBMI for A-CRA. Thus, future efforts focused on implementing A-CRA could be improved by measuring and monitoring the extent to which A-CRA procedures are being delivered to clients. Additionally, given the dearth of studies that have examined the relationship between organizational-level measures of implementation and client outcomes, this article provides a prototype for future research to identify EBMIs for other behavioral treatments.

Associations between implementation characteristics and evidence-based practice sustainment: a study of the Adolescent Community Reinforcement Approach

Background

Few empirical studies longitudinally examine evidence-based practice (EBP) sustainment and the hypothesized factors that influence it. In an effort to address this gap, the current study examined sustainment of an EBP for adolescent substance use called the adolescent community reinforcement approach (A-CRA).

Methods

A-CRA sustainment was assessed via information collected as part of key informant interviews and surveys with clinical staff from community-based treatment organizations that had received federal funding to implement A-CRA. Administrative data from the funding period on implementation was also used. Using discrete-time survival analysis, we regressed A-CRA sustainment on several factors theorized to influence EBP sustainment. Factors examined included outer setting, inner setting, implementation quality during the funding period, and intervention-related characteristics.

Results

Overall, data from 83 % of the targeted sample of treatment organizations was collected. A-CRA sustainment was strongly related to the time since funding loss. Strong relationships were found between sustainment status and implementation quality during the funding period, agency focus, funding stability, and political support for the treatment along with staff perceptions of the treatment’s complexity and implementation difficulty.

Conclusions

Consistent with the Consolidated Framework for Implementation Research, the current study found several factors related to the outer setting (e.g., funding stability), inner setting (e.g., agency focus), implementation quality during the funding period (e.g., staff trained, clients served), and characteristics of the intervention (e.g., implementation complexity) to be associated with EBP sustainment. Future research is warranted to examine the extent to which these relationships are stable over time. Efforts to ensure that adequate implementation occurs during the initial implementation period and that adequate funding, infrastructure, and staff support following the ending of initial support are critical to a program’s survival.

The relationship between recovery and health-related quality of life

Building upon recommendations to broaden the conceptualization of recovery and to assess its relationship with health-related quality of life (HRQoL), this study addressed three primary aims. These included: 1) testing the model fit of a hypothesized latent measure of recovery, 2) examining the extent to which this multidimensional measure of recovery was associated with concurrently measured HRQoL, and 3) examining the extent to which this multidimensional measure of recovery predicted changes in HRQoL during the subsequent year. Data were from 1,008 adults who completed follow-up assessments at 15 and 16 years post-intake. Confirmatory factor analysis indicated a good fit for a hypothesized recovery measure (CFI=.98; RMSEA=.06). Additionally, structural equation modeling suggested that this recovery measure was not only concurrently associated with HRQoL (β=.78, p<.001), but was also a significant predictor of changes in HRQoL during the subsequent year (β=.25, p<.001).

Predictors of Staff Turnover and Turnover Intentions within Addiction Treatment Settings: Change Over Time Matters

This study examined the extent to which changes over time in clinicians’ responses to measures of work attitude (eg, job satisfaction) and psychological climate (eg, supervisor support) could predict actual turnover and turnover intentions above and beyond absolute levels of these respective measures. Longitudinal data for this study were collected from a sample of clinicians (N = 96) being trained to implement an evidence-based treatment for adolescent substance use disorders. Supporting findings from a recent staff turnover study, we found job satisfaction change was able to predict actual turnover above and beyond average levels of job satisfaction. Representing new contributions to the staff turnover literature, we also found that change over time in several other key measures (eg, job satisfaction, role manageability, role clarity) explained a significant amount of variance in turnover intentions above and beyond the absolute level of each respective measure. A key implication of the current study is that organizations seeking to improve their ability to assess risk for staff turnover may want to consider assessing staff at multiple points in time in order to identify systematic changes in key employee attitudes like turnover intentions and job satisfaction.

Examining the sustainment of the Adolescent-Community Reinforcement Approach in community addiction treatment settings: protocol for a longitudinal mixed method study

BACKGROUND

Although evidence-based treatments are considered the gold standard for clinical practice, it is widely recognized that evidence-based treatment implementation in real world practice settings has been limited. To address this gap, the federal government provided three years of funding, training and technical assistance to 84 community-based treatment programs to deliver an evidence-based treatment called the Adolescent-Community Reinforcement Approach (A-CRA). Little is known about whether such efforts lead to long-term A-CRA sustainment after the initial funding ends.

METHODS/DESIGN

We will use a longitudinal mixed method data analytic approach to characterize sustainment over time and to examine the factors associated with the extent to which A-CRA is sustained. We will use implementation data collected during the funding period (e.g., organizational functioning, staff certification rates and penetration) and supplement it with additional data collected during the proposed project period regarding implementation quality and the hypothesized predictors of sustainment (i.e., inner and outer contextual variables) collected over three waves from 2013 to 2015 representing program sustainment up to five years post-initial funding.

DISCUSSION

Gaining a better understanding of the factors that influence the evidence-based treatment sustainment may lead to more effective dissemination strategies and ultimately improve the quality of care being delivered in community-based addiction treatment settings.

The relationship between child maltreatment and substance abuse treatment outcomes among emerging adults and adolescents

Emerging adulthood is the period of greatest risk for problematic substance use. The primary aim of the current study was to examine the relationship between a broad measure of child maltreatment and several key outcomes for a large clinical sample of emerging adults (n = 858) and adolescents (n = 2,697). The secondary aim was to examine the extent to which the relationship between child maltreatment and treatment outcomes differed between emerging adults and adolescents. Multilevel latent growth curve analyses revealed emerging adults and adolescents who experienced child maltreatment reported significantly greater reductions over time on several treatment outcomes (e.g., substance use, substance-related problems, and emotional problems). Overall, analyses did not support differential relationships between child maltreatment and changes over time in these substance use disorder treatment outcomes for emerging adults and adolescents. The one exception was that although emerging adults with child maltreatment did reduce their HIV risk over time, their improvements were not as great as were the improvements in HIV risk reported by adolescents who had experienced child maltreatment.

A Behaviorally-Anchored Rating System to Monitor Treatment Integrity for Community Clinicians Using the Adolescent Community Reinforcement Approach

This study evaluated a process for training raters to reliably rate clinicians delivering the Adolescent Community Reinforcement Approach (A-CRA) in a national dissemination project. The unique A-CRA coding system uses specific behavioral anchors throughout its 73 procedure components. Five randomly-selected raters each rated "passing" and "not passing" examples of the 19 A-CRA procedures. Ninety-four percent of the final ICCs were at least 'good' (≥.60) and 66.7% were 'excellent' (≥.75), and 95% of the ratings exceeded the 60% or better agreement threshold between raters and the gold standard. Raters can be trained to provide reliable A-CRA feedback for large-scale dissemination projects.

Recovery Support for Adolescents with Substance use Disorders: The Impact of Recovery Support Telephone Calls Provided by Pre-Professional Volunteers

The present quasi-experiment examined the direct and indirect effects of recovery support telephone calls following adolescent substance use disorder treatment. Six-month outcome data from 202 adolescents who had received recovery support calls from primarily pre-professional (i.e., college-level social service students) volunteers was compared to 6-month outcome data from a matched comparison sample of adolescents (n = 404). Results suggested adolescents in the recovery support sample had significantly greater reductions in their recovery environment risk relative to the comparison sample (β = -.17). Path analysis also suggested that the reduction in recovery environment risk produced by recovery support calls had indirect impacts (via recovery environment risk) on reductions in social risk (β = .22), substance use (β = .23), and substance-related problems (β = .16). Finally, moderation analyses suggested the effects of recovery support calls did not differ by gender, but were significantly greater for adolescents with lower levels of treatment readiness. In addition to providing rare empirical support for the effectiveness of recovery support services, an important contribution of this study is that it provides evidence that recovery support services do not necessarily have to be "peer-based," at least in terms of the recovery support service provider having the experiential credentials of being "in recovery." If replicated, this latter finding may have particularly important implications for helping increase the recovery support workforce.

The GAIN Short Screener (GSS) as a Predictor of Future Arrest or Incarceration Among Youth Presenting to Substance Use Disorder (SUD) Treatment

The National Institutes of Health (NIH) data harmonization project on existing measures (www.phenx.org) has recommended the Global Appraisal of Individual Needs (GAIN)—Short Screener (GSS) as one of the most reliable, valid, efficient, and inexpensive general behavioral health screeners to quickly identify people with internalizing and externalizing mental health disorders, substance use disorders, and crime/violence problems. The present study examined how well the four GSS screeners and their sum predict future arrest or incarceration among individuals entering treatment for a substance use disorder. Using a cross-validation design, a diverse sample of 6,815 youth with substance use disorders was split into a development sample and a validation sample. Overall, results found the GSS’s crime and violence screener (CVScr) and the substance disorder screener (SDScr) to be the two best predictors of arrest/incarceration within the 12 months following treatment intake. Additionally, we found that these screeners could be used to categorize individuals into three groups (low risk, moderate risk, high risk) and this simplified classification had good predictive validity (Area Under the Curve = 0.601). In sum, the GSS’s predictive validity was similar to other instruments that have been developed to predict risk for recidivism; however, the GSS takes only a fraction of the time to collect (ie, approximately 2–3 minutes for just these two screeners).

Using pay for performance to improve treatment implementation for adolescent substance use disorders: results from a cluster randomized trial

OBJECTIVE

To test whether pay for performance (P4P) is an effective method to improve adolescent substance use disorder treatment implementation and efficacy.

DESIGN

Cluster randomized trial.

SETTING

Community-based treatment organizations.

PARTICIPANTS

Twenty-nine community-based treatment organizations, 105 therapists, and 986 adolescent patients (953 with complete data).

INTERVENTION

Community-based treatment organizations were assigned to 1 of the following conditions: the implementation-as-usual (IAU) control condition or the P4P experimental condition. In addition to delivering the same evidence-based treatment (ie, using the Adolescent Community Reinforcement Approach [A-CRA]), each organization received standardized levels of funding, training, and coaching from the treatment developers. Therapists in the P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (ie, A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions (ie, target A-CRA) that has been found to be associated with significantly improved patient outcomes.

MAIN OUTCOME MEASURES

Outcomes included ACRA competence (ie, a therapist-level implementation measure), target A-CRA (ie, a patient-level implementation measure), and remission status (ie, a patient-level treatment effectiveness measure).

RESULTS

Relative to therapists in the IAU control condition, therapists in the P4P condition were significantly more likely to demonstrate A-CRA competence (24.0% vs 8.9%; event rate ratio, 2.24; 95% CI, 1.12- 4.48; P=.02). Relative to patients in the IAU control condition, patients in the P4P condition were significantly more likely to receive target A-CRA (17.3% vs 2.5%; odds ratio, 5.19; 95% CI, 1.53-17.62; P=.01). However, no significant differences were found between conditions with regard to patients' end-of-treatment remission status.

CONCLUSION

Pay for performance can be an effective method of improving treatment implementation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01016704

The relationship between clinician turnover and adolescent treatment outcomes: an examination from the client perspective

The turnover of substance use disorder (SUD) treatment staff has been assumed to adversely impact treatment effectiveness, yet only limited research has empirically examined this assumption. Representing an extension of prior organizational-level analyses of the impact of staff turnover on client outcomes, this study examined the impact of SUD clinician turnover on adolescent treatment outcomes using a client perspective. Multilevel regression analysis did reveal that relative to those adolescents who did not experience clinician turnover, adolescents who experienced both direct and indirect clinician turnover reported a significantly higher percentage of days using alcohol or drugs at 6-month follow-up. However, clinician turnover was not found to have significant associations (negative or positive) with the other five treatment outcomes examined (e.g., substance-related problems, involvement in illegal activity). Thus, consistent with our prior findings, the current study provides additional evidence that turnover of SUD clinicians is not necessarily associated with adverse treatment outcomes.

The Brief Treatment Cost Analysis Tool (TCAT-Lite) for Substance Abuse Treatment: Reliability and Application

Although several costing instruments have been previously developed, few have been validated or applied systematically to the delivery of evidence-based practices (EBPs). Using data collected from 26 organizations implementing the same EBP, this paper examined the reliability, validity, and applicability of the brief Treatment Cost Analysis Tool (TCAT-Lite). The TCAT-Lite demonstrated good reliability-correlations between replications averaged 0.61. Validity also was high, with correlation of treated episodes per $100,000 between the TCAT-Lite and independent data of 0.57. In terms of applicability, cost calculations found that if all organizations had operated at optimal scale (124 client episodes per year), existing funds could have supported 64% more clients.