Expand Treatment Capacity Research Articles

Ammonia stripping and scrubbing followed by nitrification and denitrification saves costs for manure treatment based on a calibrated model approach

Resource-efficient nitrogen management is of high environmental and economic interest, and manure represents the major nutrient flow in livestock-intensive regions. Ammonia stripping/scrubbing (SS) is an appealing nitrogen recovery route from manure, yet its real-life implementation has been limited thus far. In nutrient surplus regions like Flanders, treatment of the liquid fraction (LF) of (co–)digested manure typically consists of nitrification/denitrification (NDN) removing most N as nitrogen gas. Integrating SS before NDN in existing plants would expand treatment capacity and recover N while maintaining low N effluent values, yet cost estimations of this novel approach after process optimisation are not yet available. A programming model was developed and calibrated to minimise the treatment costs of this approach and find the balance between N recovery versus N removal. Four crucial operational parameters (CO2 stripping time, NH3 stripping time, temperature and NaOH addition) were optimised for 18 scenarios which were different in terms of technical set-up, influent characteristics and scrubber acid. The model shows that SS before NDN can decrease the costs by 1 to 56% under optimal conditions compared to treatment with NDN only, with 1 to 8% reduction for the LF of manure (22–29% recovered of N treated), and 11 to 56% reduction for the LF of co-digested manure (42–67% recovered of N treated), primarily dependent on resource pricing. This study shows the power of modelling for minimum-cost design and operation of manure treatment yielding savings while producing useful N recovery products with SS followed by NDN.

Building a statewide network of MOUD expertise using tiered ECHO® mentoring opportunities

BackgroundExpanding access to workforce training for opioid use disorder (OUD) treatment continues to be a priority. This study explored the use of tiered mentoring opportunities within an ECHO® model to expand treatment capacity and develop a statewide network of medications for OUD (MOUD) expertise. ECHO® engages participants in a virtual community to learn best practices through case-based learning and interactions with experts. MethodsWe studied two incentivized Illinois MOUD ECHO® training programs by examining aggregate demographic and prescribing data across eight training cohorts (n = 199 participants). Participants (n = 51) in the last two cohorts were evaluated with expanded pre- and post-training surveys. Qualitative interviews were completed with a subset (n = 13) to examine effects observed in the survey data. ResultsFor the whole group, we found a geographic expansion of the participants’ prescribing capacity that reached into rural and other underserved areas in Illinois. Participants in the last two cohorts reported both increased self-efficacy for OUD treatment and increased connectedness to the addiction treatment community in Illinois. Participants who progressed through the tiered mentorship roles were found to exhibit stepwise increases in reported self-efficacy and connectedness measures. ConclusionAn incentivized ECHO® program yielded substantive outcomes in terms of increased prescribing capacity across the state. The use of tiered mentoring opportunities enabled participants to develop MOUD expertise and support novice providers in a growing statewide network. There is potential to train professionals to a high level of expertise when the ECHO® model is combined with a mentorship pathway.

Association Between Interorganizational Collaboration in Opioid Response and Treatment Capacity for Opioid Use Disorder in Counties of Five States: A Cross-Sectional Study.

Background:Local governments on the front lines of the opioid epidemic often collaborate across organizations to achieve a more comprehensive opioid response. Collaboration is especially important in rural communities, which can lack capacity for addressing health crises, yet little is known about how local collaboration in opioid response relates to key outputs like treatment capacity.Purpose:This cross-sectional study examined the association between local governments’ interorganizational collaboration activity and agonist treatment capacity for opioid use disorder (OUD), and whether this association was stronger for rural than for metropolitan communities.Methods:Data on the location of facilities providing buprenorphine and methadone were merged with a 2019 survey of all 358 counties in 5 states (CO, NC, OH, PA, and WA) that inquired about their collaboration activity for opioid response. Regression analysis was used to estimate the effect of a collaboration activity index and its constituent items on the capacity to provide buprenorphine or methadone in a county and whether this differed by urbanicity.Results:A response rate of 47.8% yielded an analytic sample of n = 171 counties, including 77 metropolitan, 50 micropolitan, and 44 rural counties. Controlling for covariates, a 1-unit increase in the collaboration activity index was associated with 0.155 (95% CI = 0.005, 0.304) more methadone facilities, ie, opioid treatment programs (OTPs), per 100 000 population. An interaction model indicated this association was stronger for rural (average marginal effect = 0.354, 95% CI = 0.110, 0.599) than for non-rural counties. Separate models revealed intergovernmental data and information sharing, formal agreements, and organizational reforms were driving the above associations. Collaboration activity did not vary with the capacity to provide buprenorphine at non-OTP facilities. Spatial models used to account for spatial dependence occurring with OUD treatment capacity showed similar results.Conclusion:Rural communities may be able to leverage collaborations in opioid response to expand treatment capacity through OTPs.

Need for and Receipt of Substance Use Disorder Treatment Among Adults, by Gender, in the United States.

Disparities in substance use disorder (SUD) treatment use persist across groups, including gender. Using a gender-informed approach to expand treatment capacity and reduce barriers to treatment engagement is vital. We examined SUD treatment need and receipt among people with SUD in the United States, by gender, and assessed gender-specific sociodemographic factors associated with unmet need for SUD treatment and reported treatment barriers. We conducted an analysis of data among adults aged ≥18 with a past-year SUD from the National Survey on Drug Use and Health (2015-2018). We computed population-adjusted frequencies and proportions for SUD treatment need and receipt and assessed gender differences. Multivariate logistic regression assessed gender-specific sociodemographic variables associated with SUD treatment receipt. Among adults with a past-year SUD, 63.4% were men and 36.6% were women (P < .001), only 10.6% received SUD treatment, and a greater percentage of women than men needed treatment for opioid use disorder (11.9% vs 9.9%; P = .002). Receipt of SUD treatment was lowest among women with alcohol use disorder followed by men with alcohol use disorder (7.5% vs 8.9%; P = .052). Non-Latinx Black men had fewer than half the adjusted odds of receiving SUD treatment than non-Latinx White men (adjusted odds ratio [aOR] = 0.44; 95% CI, 0.27-0.71). Latinx women (aOR = 0.37; 95% CI, 0.18-0.73) and non-Latinx Black women (aOR = 0.51; 95% CI, 0.27-0.94) had significantly lower odds of receiving SUD treatment than non-Latinx White women. As public health efforts target expanding SUD treatment capacity and addressing disparities in use of SUD treatment, interventions informed by gender and culture should be prioritized.

US national treatment admissions with opioids and benzodiazepines.

Opioids and benzodiazepines (O/BZD) are increasingly involved in drug overdose deaths in the USA. Expanding treatment capacity may reduce these deaths. Knowledge about co-occurring O/BZD admissions compared to opioid admissions (opioid) is needed to plan this expansion. US treatment admissions to specialty facilities for 2011-2017 were analysed for trends and 2017 for group differences. Due to 1.9 million admissions in 2017, comparisons between O/BZD and opioid admissions were summarised as effect sizes. Additional analysis compared the administratively pre-coded category 'other opiates and synthetics' to other opiates and synthetics/benzodiazepines admissions to control for possible similarity in drug source. Differences within O/BZD admissions by primary drug were explored. Although opioid admissions showed a steady increase over time (25.9% to 38.2%), O/BZD admissions showed increases until decline in 2017 (3.2% to 4.0%). In 2017 no factor reached moderate effect size (≥0.2) in group comparisons or within the O/BZD admissions. Heroin was self-reported in 70% of both O/BZD and opioid admissions. No meaningful US national differences on data routinely collected were found for O/BZD compared to opioid admissions including the subgroup with other opiates and synthetics only. Efforts to expand existing opioid treatment in specialty treatments may help reduce opioid and O/BZD deaths. However, the analysis could not address whether changes in treatment would improve outcomes.

Briefly Noted

The Substance Abuse and Mental Health Services Administration (SAMHSA) has announced the availability of more than $10 million in grant funding to expand treatment capacity for substance use disorders in family treatment drug courts. The Funding Opportunity Announcement, posted Nov. 5, states that the application due date is Jan. 4, 2019. “The purpose of this program is to expand substance use disorder (SUD) treatment services in existing family treatment drug courts, which use the family treatment drug court model in order to provide alcohol and drug treatment (including recovery support services, screening, assessment, case management, and program coordination) to parents with a SUD and/or co‐occurring SUD and mental disorders who have had a dependency petition filed against them or are at risk of such filing,” according to the announcement. “Services must address the needs of the family as a whole and include direct service provision to children (18 and under) of individuals served by this project.” Grant recipients must provide an approach that combines the “sanctioning power” of treatment drug courts with treatment services that promote successful family preservation and reunification. “Priority funding should address gaps in the treatment continuum for court involved individuals who need treatment for a SUD and/or co‐occurring SUD and mental disorders while simultaneously addressing the needs of their children,” according to the announcement. The funding is to help participants reduce substance misuse, reduce SUD and co‐occurring disorder severity and decrease out‐of‐home placements for children, according to the announcement, which goes on to say that this “should also decrease the number of parents or guardians whose parental rights have been or will be terminated.” Eligible applicants include state governments and territories, counties, cities or towns, as well as federally recognized tribal organizations and consortia. Family treatment drug courts that received an award for FY 2017 or FY 2018 under this program are not eligible to apply. An anticipated 25 awards will be given, with award amounts of up to $425,000 a year for up to five years. No cost sharing is required. For more information, contact Jon.Berg@samhsa.hhs.gov

Expanding Capacity to Treat Hepatitis C: Overcoming Barriers and New Innovations

Chronic hepatitis C virus (HCV) infection remains a global public health burden and is associated with significant morbidity and mortality. Despite significant advances in the safety and efficacy of antiviral therapy since 2014 due to the rise of oral direct acting antiviral (DAA) regimens, ongoing deficits persist across the care cascade in the USA which will limit success in achieving the objectives of the US National Academies of Sciences, Engineering, and Medicine and the World Health Organization to eliminate chronic HCV in the USA and worldwide. In this review, we discuss the critical role of expanding treatment capacity to enhance these efforts through a multifaceted strategy which incorporates education, training, and multidisciplinary support across clinical settings such as specialty centers, primary care, community health centers, methadone and substance use programs, prisons, and pharmacy-based clinics. Further investment by multiple stakeholders including governmental and non-governmental organizations, public health agencies, medical societies, and advocacy groups will be necessary to meaningfully effect change.

Medication-Assisted Opioid Treatment Prescribers in Federally Qualified Health Centers: Capacity Lags in Rural Areas.

This study explores correlates of on-site availability of substance use disorder treatment services in federally qualified health centers, including buprenorphine treatment that is critical to addressing the opioid epidemic. We employed descriptive and multivariable analyses with weighted 2010 Assessment of Behavioral Health Services survey data and the 2010 Uniform Data System. In 2010, 47.6% of health centers provided on-site substance use disorder treatment, 12.3% provided buprenorphine treatment for opioids, and 38.8% were interested in expanding buprenorphine availability. Urban health centers, those in the West, and health centers with electronic health records had higher odds of offering on-site substance use disorder treatment. Compared with on-site mental health treatment, substance use disorder treatment was available in fewer clinic sites within each organization. Health centers in rural areas had lower odds of providing on-site buprenorphine treatment (OR = 0.49, 95% CI: 0.26-0.94), and those in the South had lower odds of providing on-site buprenorphine treatment compared with health centers in other regions. Rural health centers had lower odds of expressing interest in expanding the availability of buprenorphine treatment (OR = 0.58, 95% CI: 0.35-0.97). Improving access to substance use disorder treatment in primary care is a critical part of the strategy to combat the opioid use disorder epidemic. These findings highlight the important role of health centers as portals of access to substance use disorder treatment services in underserved communities. Recent investments to expand treatment capacity in health centers will expand the availability of substance use disorder services, but urban/rural and regional disparities should be monitored.

Bending the curve: force health protection during the insertion phase of the Ebola outbreak response

After >10 years of enduring operations in Iraq and Afghanistan, Defence Strategic Direction is returning to a contingency posture. As the first post-Afghanistan operation, in September 2014, a UK Joint...

Enabling lay providers to conduct CBT for older adults: key steps for expanding treatment capacity.

The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.

The Plight of Providing Appropriate Substance Abuse Treatment Services to Offenders: Modeling the Gaps in Service Delivery

Using data from the National Criminal Justice Treatment Practices (NCJTP) Survey, estimates of offenders participating in drug treatment services were generated. Existing drug treatment programs have a capacity to serve around 10% of offenders. The majority of available services are alcohol and drug education and group counseling, which are suited for people with low-threshold substance use disorders. Yet a third of the offenders are reported to have a severe disorder (dependency) requiring more intensive structured services. Offenders in prison and jail are more likely to have access to treatment services compared to offenders in the community. Regardless of the correctional setting, only a small portion of the offender population receives the appropriate level of treatment. The current delivery system is inadequate to reduce the risk of recidivism. Using the risk, need, and responsivity framework to address the adequacy of dealing with drug-involved offenders, the current service delivery does not embrace this model. An effective correctional system should not only expand treatment capacity but also provide appropriate services given the needs of offenders. The composition of the current system demands attention to providing more intensive services to effectively use resources and to focus on risk reduction strategies.

Integrated, home-based treatment for MDR-TB and HIV in rural South Africa: an alternate model of care.

Treatment outcomes for multidrug-resistant tuberculosis (MDR-TB) in South Africa have suffered as centralized, in-patient treatment programs struggle to cope with rising prevalence and human immunodeficiency virus (HIV) co-infection rates. A new treatment model is needed to expand treatment capacity and improve MDR-TB and HIV outcomes. To describe the design and preliminary results of an integrated, home-based MDR-TB-HIV treatment program created in rural KwaZulu-Natal. In 2008, a decentralized center was established to provide out-patient MDR-TB and HIV treatment. Nurses, community health workers and family supporters have been trained to administer injections, provide adherence support and monitor adverse reactions in patients' homes. Physicians assess clinical response, adherence and the severity of adverse reactions to MDR-TB and HIV treatment at monthly follow-up visits. Treatment outcomes are assessed by monthly cultures and CD4 and viral load every 6 months. Of 80 patients initiating MDR-TB treatment from February 2008 to April 2010, 66 were HIV-co-infected. Retention has been high (only 5% defaults, 93% of visits attended), and preliminary outcomes have been favorable (77% cured/still on treatment, 82% undetectable viral load). Few patients have required escalation of care (9%), had severe adverse events (8%) or died (6%). Integrated, home-based treatment for MDR-TB and HIV is a promising treatment model to expand capacity and achieve improved outcomes in rural, resource-poor and high HIV prevalent settings.

A Review of Ohio's Treatment Capacity in Addressing the State's Opiate Epidemic

Ohio is currently in the midst of an opiate epidemic. Persons seeking treatment for opiate addiction are now inundating treatment centers in every region of the state. To understand further the capacity of Ohio’s treatment system to address the needs of opiate abusing and dependent clients, the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) surveyed all treatment providers regarding service wait times and treatment barriers. Nearly 80 percent of providers statewide participated (N = 193). Results concluded that the proportion of clients accessing services across Ohio with an opiate abuse/dependence diagnosis has increased over the past 12 months. Almost a third of providers reported that opiate addicted clients now make up more than a quarter of all clients served. The state’s current treatment system is challenged in addressing the needs of Ohio’s rapidly increasing number of opiate addicted clients. Nearly 80 percent of providers reported wait times for assessment services; providers most frequently reported wait times of several weeks for residential treatment; and practically half of referring providers to Suboxone®, and the majority of those referring to methadone programs, indicated difficulty in getting clients enrolled in medication-assisted treatment, citing capacity issues such as no program openings for methadone and lack of licensed physicians for Suboxone®. The opiate epidemic has increased wait times for treatment services across the state, further straining Ohio's treatment capacity in an already challenged behavioral healthcare system. New policies are needed to expand treatment capacity and to limit nonmedical use of prescription opiates.

Buprenorphine therapy for opioid addiction in rural Washington: The experience of the early adopters

The introduction of buprenorphine as office-based treatment for opioid dependence was designed to expand treatment capacity, but virtually there are no data about use of this medication in rural areas. The survey of the first cohort of physicians in rural Washington State who obtained buprenorphine waivers (2002-2010) to determine the volume of treated patients, physician appraisal of the efficacy of this treatment, and perceived barriers to treatment was conducted. Twenty-four (73 percent) of the 33 rural buprenorphine-certified physicians practicing in the state were interviewed in 2010. Twenty physicians (83 percent) were actively prescribing buprenorphine/naloxone for treatment of addiction. Those currently prescribing averaged 23 active patients and had treated 125 patients since certification. All respondents reported that buprenorphine was efficacious in the treatment of addiction and 95 percent recommended that other rural colleagues adopt buprenorphine treatment. The following four major barriers were cited: 1) lack of adequate financial support from Medicaid, the largest source of third-party coverage for these patients; 2) unavailability of local mental health and behavioral addiction treatment services; 3) difficulty in finding consultants to assist in managing complex patients; and 4) shortages of other rural physicians providing this service. Buprenorphine is viewed as a highly effective treatment of opioid addiction by early adopters in rural Washington State, but relatively few rural physicians currently provide this service. Inadequate insurance coverage, a shortage of effective links with consultants and colleagues, and the lack of mental health services are persistent barriers to the use of this modality in rural Washington State.

The BHIVES Collaborative: Organization and Evaluation of a Multisite Demonstration of Integrated Buprenorphine/Naloxone and HIV Treatment

Substance abuse is associated with poor medical and quality-of-life outcomes among HIV-infected individuals. Although drug treatment may reduce these negative consequences, for many patients, options are limited. Buprenorphine/naloxone, an opioid agonist treatment that can be prescribed in the United States in office-based settings, can be used to expand treatment capacity and integrate substance abuse services into HIV care. Recognizing this potential, the US Health Resources and Services Administration funded the development and implementation of demonstration projects that integrated HIV care and buprenorphine/naloxone treatment at 10 sites across the country. An Evaluation and Technical Assistance Center provided programmatic and clinical support as well as oversight for an evaluation that examined the processes for and outcomes of integrated care. The evaluation included patient-level self-report and chart abstractions as well as provider and site level data collected through surveys and in-depth interviews. Although multisite demonstrations pose implementation and evaluation challenges, our experience demonstrates that these can, in part, be addressed through ongoing communication and technical assistance as well as a comprehensive evaluation design that incorporates multiple research methods and data sources. Although limitations to evaluation findings persist, they may be balanced by the scope and "real-world" context of the initiative.

Expanding treatment capacity for opioid dependence with office-based treatment with buprenorphine: National surveys of physicians

Office-based treatment of opioid dependence with buprenorphine has the potential to expand treatment capacity in the United States. However, nationally, little is known about the number, characteristics, and experiences of physicians certified to prescribe buprenorphine. Moreover, little is known about the impact of easing federal regulations on the number of patients a physician is allowed to treat concurrently. To address these questions, surveys of national samples of physicians certified to prescribe buprenorphine (2004–2008) were analyzed ( N = 6,892). There has been a continual increase in the number of physicians certified to prescribe buprenorphine, increase in the mean number of patients treated by physicians, and decrease in patients turned away, coinciding temporally with easing of federal regulations. In addition, most physicians prescribed buprenorphine outside of traditional treatment settings. The U.S. experiment in expanding Schedule III-V medications for opioid dependence to physicians outside of formal substance abuse treatment facilities appears to have resulted in expanded capacity.

Solutions to Expand Treatment and Disposal Capacity of a Lagoon Facility in Environmentally Sensitive Area

Solutions to Expand Treatment and Disposal Capacity of a Lagoon Facility in Environmentally Sensitive Area

Membranes and wastewater: Modular treatment systems offer solutions

Chris King, GE Water & Process Technologies, outlines why upgrades may be required at wastewater treatment works (WWTW) to improve effluent quality, increase the potential to re-use water or expand treatment capacity. Membrane ultrafiltration (UF) technology, in combination with appropriate bioreactor systems seem to offer a viable solution.

Capital-Intensive Privatization

The City of Auburn, Alabama, a university city of 45,000, privatized its wastewater treatment facilities in the early 1980s. At the time, the city was faced with outdated wastewater facilities that were built in the 1950s. Overflows from the many pump stations into local creeks were common occurrences. Federal financial assistance was several years away because of Auburn’s lower priority on the funding list, and interest rates were very high for municipal bond issues. Federal tax law favored private investment in public facilities so the city choose a private company to build, own, and operate two new treatment plants. In 2001, the city purchased the treatment facilities from the private owner because it needed to expand treatment capacity and build a major new sewer line. This article presents the case study of the privatization and subsequent return to public ownership of a capital-intensive privatization project of the early 1980s.

Prevalence of DSM-IV Substance Abuse and Dependence Disorders Among Prison Inmates

The study examined the 30-day and lifetime prevalence of DSM-IV alcohol and drug disorders among state prison inmates. A sample of 400 inmates consecutively admitted to a state prison reception center were assessed for alcohol and drug disorders using the Structured Clinical Interview for DSM-IV (SCID-IV). Test-retest reliabilities were calculated for the SCID-IV. Lifetime substance abuse or dependence disorders were detected among 74% of inmates, including over half who were dependent on alcohol or drugs. for the 30 days prior to incarceration, over half of the sample were diagnosed as having substance abuse or dependence disorders, including 46% who were dependent on alcohol or drugs. Black inmates were significantly less likely to be diagnosed as alcohol dependent than whites or Hispanics. the high rates of substance use disorders are consistent with previous findings from other studies conducted in correctional settings and reflect the need to expand treatment capacity in prisons.