Substance Use Disorder Treatment Settings Research Articles

Identifying best practices for substance-related intimate partner violence screening and referral: a narrative review.

Substance use is strongly associated with intimate partner violence (IPV) and is a modifiable risk factor for IPV. However, lack of comprehensive screening and referral for co-occurring IPV and substance use, along with their psychiatric sequalae, limits the identification and implementation of effective interventions for substance-related IPV. This narrative review (1) investigates the literature on screening and referral practices for IPV, and if these include screening for substance use or other psychiatric comorbidities, (2) provides recommendations for current best practices, and (3) suggests future directions for research and practice aimed at identifying and reducing substance-related IPV. A narrative literature review examined studies investigating IPV screening and referral programs in clinics. Selected studies were reviewed for: (1) effectiveness, (2) barriers to implementation and sustainability, and (3) responsivity to psychiatric comorbidity, including substance use and substance use disorders (SUD). Findings suggest that effective IPV screening and referral programs have been developed, but disparities in IPV screening exist and many programs only screen for IPV victimization. Barriers to the implementation and sustainability of IPV screening programs include lack of ongoing provider training, funding or institutional support, and direct connection to referral services. Further, many IPV screening programs lack assessment of and referral for comorbid psychiatric conditions, including substance use, and tend not to be routinely implemented in SUD clinics. Additional systematic work is needed to develop universal and comprehensive screening and referral programs for substance-related IPV and address issues of long-term sustainability, particularly within SUD treatment settings.

An opt-out tobacco treatment group intervention within an intensive substance use disorders treatment program: Initial outcomes in the Veterans Health Administration.

Despite steadily declining rates of tobacco use in the United States, individuals suffering from substance use disorders (SUD) and other mental illnesses continue to use tobacco at alarmingly high rates, resulting in increased mortality. Given the synergistic consequences to those who suffer from both tobacco use disorders (TUD) and other SUD, embedding tobacco treatment into structured SUD programs using an opt-out approach may yield a greater impact. The current study compares clinical outcomes (i.e., quit attempts and prescription of tobacco cessation medications) for an opt-out versus opt-in approach to tobacco treatment. Tobacco use information was collected prior to and after implementation of an opt-out, eight-session, tobacco group treatment intervention. Patient self-report and medical chart review were utilized to identify individuals who began a tobacco cessation medication during treatment as well as those who reported quitting tobacco, defined as sustained tobacco abstinence for at least seven days. The analysis includes a total of N = 332 Veterans who enrolled in the Intensive Outpatient Program (IOP). Those enrolled in the opt-out tobacco treatment group reported a significantly higher rate of quitting tobacco (24.57%) than those in the opt-in group (2.55%; p <.001). Likewise, the opt-out group was prescribed tobacco cessation medications at a significantly higher rate than the opt-in group (55.00% compared to 14.65%; p <.001). An opt-out treatment approach to TUD in SUD treatment settings produced improved outcomes, including significantly more patients engaged in TUD treatment and a higher overall rate of SUD treatment completion. Given the disproportionately high rate of tobacco use among those seeking treatment for SUD, enhanced tobacco cessation interventions could result in both improved tobacco as well as other substance use outcomes. The implementation of an opt-out tobacco treatment intervention embedded into SUD programming is supported by our findings of reduced tobacco use among patients.

Using Measurement-Based Care as a Precision Medicine Strategy for Substance Use Disorders.

Precision medicine prioritizes characterization of individual patient parameters to optimize care and this review evaluates measurement-based care (MBC) as a strategy for doing so in the treatment of substance use disorders (SUD). Measurement-based care refers to the systematic use of validated assessments to inform diagnosis and treatment planning, with varying frequency of assessments. Despite the seemingly obvious grounds for the use of MBC in treating SUD, systematic implementation to date has been limited. Thus, the goal of this review is to evaluate efforts to date and to stimulate greater consideration of MBC models in addictions programs. Data from two published randomized controlled trials and findings from pragmatic clinical research highlight the potential utility of MBC in the SUD treatment settings. Despite these findings, the existing literature indicates the high need for larger-scale clinical trials and quality improvement programs. Potential barriers to the implementation of MBC for SUD are outlined at the patient, provider, organization, and system levels, as well as the challenges associated with the use of MBC programs for clinical research. Critical thinking considerations and risk mitigation strategies are offered toward advancing MBC for SUD beyond the current nascent state. Collectively, the existing data confirm that MBC is a suitable and promising strategy for applying a precision medicine approach in SUD treatment, warranting further implementation efforts and scientific inquiry.

Peer Facilitator Training for Diabetes Prevention in a Nigerian Drug Treatment Center.

Individuals with substance use disorders (SUDs) are at an increased risk of developing comorbid medical conditions, including Type 2 diabetes. Although the diabetes prevention program (DPP) is efficacious and cost-effective, there is no published evidence to support its implementation in Nigeria or within SUD treatment settings. In this first known DPP within an SUD treatment program, we implemented a multiphased, nurse-led DPP at a small outpatient drug treatment center in Nigeria. The aim of this article was to describe only the processes utilized for the initial peer facilitator (PF) training (Phase 1). In Phase 1, a diabetes prevention master trainer delivered a virtual DPP training to the facility's lead nurse, who return-demonstrated the DPP workshop skills and competencies over four 4-hour sessions. The lead nurse then independently delivered four 8-hour training sessions to a small number of client volunteers (n = 4) who subsequently delivered the DPP lifestyle interventions to their peers in the outpatient treatment program. The client volunteers attended all PF workshop sessions and were observed to be proficient in all aspects of implementation. They indicated that the training objectives were easily achieved and expressed enthusiasm for delivering DPP content to their peers. The need to better contextualize the DPP curriculum specific to Nigerian food preferences was identified. The Phase 1 training process appears to be an appropriate and effective approach for preparing PFs to deliver health programs, like the DPP, in environments with limited resources for populations facing numerous challenges.

Psychometric Evaluation of an Adapted Short-Form Spirituality Scale in a Sample of Predominantly White Adults in an Inpatient Substance Use Disorder Treatment Program.

Spirituality is an important aspect of treatment and recovery for substance use disorders (SUDs), but ambiguities in measurement can make it difficult to incorporate as part of routine care. We evaluated the psychometric properties of an adapted short-form version of the Spirituality Scale (the Spirituality Scale-Short-Form; SS-SF) for use in SUD treatment settings. Participants were adult patients (N = 1,388; Mage = 41.23 years, SDage = 11.55; 68% male; 86% White) who entered a large, clinically mixed inpatient SUD treatment program. Factor analysis supported the two-dimensional structure, with factors representing Self-Discovery and Transcendent Connection. Tests of measurement invariance demonstrated that the scale was invariant across age and gender subgroups. The SS-SF exhibited convergent and concurrent validity via associations with participation in spiritual activities, hopefulness, life satisfaction, 12-step participation, and depressive symptoms. Finally, scores on the SS-SF were significantly higher at discharge compared to admission, demonstrating short-term sensitivity to change. These findings support use of the SS-SF as a concise, psychometrically sound measure of spirituality in the context of substance use treatment.

Investigating the role of interpersonal relationships on low-income SUD patients’ recovery: a qualitative analysis of various stakeholders in New York state

Background While positive impacts of recovery capital and social capital in facilitating substance use disorder (SUD) recovery is increasingly documented, research has shown that low-income and marginalized individuals have lower social capital and may rely on different networks. A more comprehensive approach is needed to understand the social capital of low-income individuals with SUD and how these relationships impact their treatment and recovery. Methods Qualitative data were gathered through semi-structured interviews and analyzed employing thematic analysis. Participants included individuals with SUD (n = 10), clinicians (n = 12), and policy leaders (n = 13). Results Three themes emerged: 1) Patients’ positive and negative interpersonal relationships with friends and family influenced decisions to seek treatment; 2) strong patient-provider relationships, often defined by the quality of SUD providers and treatment settings, were perceived as crucial for staying in treatment; and 3) justice involvement facilitated treatment access yet deteriorated treatment engagement. Themes emphasized social and structural factors that inhibit patients from fostering support and treatment engagement. Conclusions Our study underscores the importance of interpersonal relationships in SUD treatment-seeking and recovery and the need for positive interactions across the care continuum within broader social networks. Opportunities for positive interpersonal relationships include increasing access to language-concordant treatment; provider training to enhance cultural humility and patient-provider relationships; and mechanisms that improve interpersonal relationships between patients, parole officers, and other justice system members. Accentuating the role of interpersonal relationships and expanding social support interventions can pave the way for structural changes that improve recovery by harnessing different types of social capital.

Predictors of Suicidal Ideation During Residential Substance Use Treatment.

Background: Individuals with substance use disorders (SUDs) and co-occurring chronic health and/or psychiatric conditions face unique challenges in treatment and may be at a greater risk for suicidal ideation relative to persons with SUD alone.Methods: In a sample of individuals entering residential SUD treatment in 2019 and 2020 (N = 10,242), we tested adjusted and unadjusted associations between suicidal ideation and (1) psychiatric symptoms and (2) chronic health conditions at treatment intake and during treatment using logistic and generalized logistic models.Results: Over a third of the sample endorsed suicidal ideation at intake, though the prevalence of suicidal ideation decreased during treatment. In both adjusted and unadjusted models, individuals who reported past-month self-harm, those who reported a lifetime suicide attempt, and individuals who screened positive for co-occurring anxiety, depression, and/or posttraumatic stress disorder were at elevated risk of endorsing suicidal ideation at intake and during treatment (P values < .001). In unadjusted models, chronic pain (odds ratio [OR] = 1.51, P < .001) and hepatitis C virus (OR = 1.65, P < .001) were associated with an elevated risk for suicidal ideation at intake, and chronic pain was associated with elevated risk for suicidal ideation during treatment (OR = 1.59, P < .001).Conclusions: Increasing accessibility to integrated treatments (ie, those that address psychiatric and chronic health conditions) for patients experiencing suicidal ideation may be beneficial in residential SUD treatment settings. Developing predictive models to identify those most at risk of suicidal ideation in real time remains a relevant direction for future work.

Experiences of Discrimination and Treatment Outcomes Among Pregnant and Postpartum People With Opioid Use Disorder [ID: 1376917

INTRODUCTION: Experiences of discrimination among pregnant and postpartum people with opioid use disorder (OUD) are common and likely affect utilization of medication for OUD (MOUD), which is associated with reduced risk of overdose and death. We aimed to examine experiences of discrimination by prenatal care (PNC) and substance use disorder (SUD) treatment settings and estimate its effect on the risk of various MOUD utilization outcomes. METHODS: Patient-stakeholders co-designed survey questions to measure self-reported outcomes related to MOUD treatment utilization, return to substance use, and overdose. First, we examined the proportion of participants who endorsed items on a modified Healthcare Discrimination Scale and summed the total scores. Next, we quantified the effect of discrimination experienced by health care setting on postpartum MOUD utilization, return to use, and overdose using log-binomial models to calculate relative risk (RR) and 95% CIs. RESULTS: Among the 100 participants enrolled in the study, 57 reported experiencing discrimination, 56 within PNC and 33 within SUD treatment settings. Discrimination within PNC (RR 2.6, CI 1.06–6.40) and SUD treatment (RR 3.26, CI 1.59–6.70) were associated with increased risk of not using MOUD as prescribed. Discrimination within SUD treatment settings correlated with an increased risk of MOUD discontinuation (RR 2.56, CI 1.19–5.54) and return to use (RR 2.36, CI 1.18–4.73). CONCLUSION: Experiences of discrimination were common, especially within prenatal care settings, and discrimination was associated with poor MOUD treatment outcomes and risk of return to use. Interventions to address discrimination within health care settings can improve outcomes for pregnant and postpartum people with OUD.

Sleep and substance use: Practice considerations for social workers

ABSTRACT Poor sleep health is consistently associated with the initiation of substance use, development of substance use disorders (SUDs), dropout from treatment, and return to use. Quality sleep health holds promise as a modifiable factor that can reduce the occurrence and severity of SUDs. Unfortunately, social workers typically receive little to no training in the assessment and evidence-based treatment of sleep disorders. This article, authored by an interdisciplinary team of clinicians and researchers, provides important sleep and SUD considerations for social workers. After providing a summary of the empirical literature surrounding the relationship between sleep and SUDs, we discuss the inclusion of the following in SUD treatment settings: (1) sleep health assessments, (2) psychoeducation on behaviors to promote healthy sleep, (3) referral to appropriate specialists when sleep disorders are suspected, (4) the promotion of a healthy sleep environment in residential treatment settings, and (5) evidenced-based behavioral interventions.

Remotely Assessing Mechanisms of Behavioral Change in Community Substance Use Disorder Treatment to Facilitate Measurement-Informed Care: Pilot Longitudinal Questionnaire Study.

Research shows that improvements in coping strategies, abstinence self-efficacy, craving, and depression are potential mechanisms of behavioral change (MOBC) in treatments for substance use disorders (SUDs). However, little is known about how these insights regarding MOBC can be applied to SUD treatment settings. One way to facilitate MOBC-informed care in frontline settings could be to measure and monitor changes in MOBC throughout treatment using brief, frequent questionnaires that patients complete by using mobile technologies (eg, smartphones). The results derived from these questionnaires could potentially be used for clinical monitoring (ie, measurement-based care) to better understand whether individual patients are experiencing treatment-related improvements on key clinical targets. This study evaluated whether brief, weekly MOBC questionnaires completed by patients remotely can potentially provide clinically meaningful information about changes in MOBC in the context of real-world, community-based SUD treatment. A total of 30 patients (14/30, 47% female; 13/30, 43% racial or ethnic minority) in a community SUD treatment clinic participated in a pilot study where they were invited to complete brief, weekly questionnaires that assessed various MOBC, including coping strategies, abstinence self-efficacy, craving, depression, and therapeutic alliance. Questionnaires were typically completed remotely via smartphone for up to 6 months; 618 questionnaires were completed in total. Participants also completed longer, psychometrically validated measures of the same MOBC at baseline and 6-month research appointments. Statistical analyses tested whether brief, weekly, remotely completed MOBC questionnaires exhibited characteristics that would be desirable for real-world longitudinal clinical monitoring, including a tendency to detect within-person changes in MOBC over time; cross-sectional and longitudinal associations with longer, psychometrically validated measures completed at research appointments; and similar patterns of associations with 6-month percentage of days abstinent as longer, psychometrically validated MOBC measures completed at research appointments. The results of this study indicated that the brief, weekly, remotely completed MOBC measures exhibited characteristics that are desirable for clinical monitoring, including a tendency to vary longitudinally (within patients over time) more often than measures of alcohol and drug consumption, generally having medium to large cross-sectional and longitudinal correlations with longer psychometrically validated measures of MOBC completed at research appointments, and generally having similar patterns of association with 6-month percentage of days abstinent from alcohol and drugs as longer psychometrically validated MOBC measures completed at research appointments. The results of this pilot study provide initial evidence that incorporating brief, weekly, and remotely completed MOBC questionnaires into community SUD treatment may be a viable approach for facilitating MOBC-informed care. Such questionnaires can potentially support measurement-based care by providing meaningful information about within-patient changes in clinical domains that are often directly targeted in SUD treatments and predict long-term substance use outcomes.

A Comparison of Sex-Specific Reproductive and Sexual Health Needs between Addiction Medicine and Primary Care Treatment Settings

Introduction: Reproductive and sexual health (RSH) is an important component of wellness and recovery for people with substance use disorder (SUD). Evidence to guide better integration of RSH services into SUD treatment is limited. Our objectives were to compare 1) unmet RSH needs; and 2) barriers to RSH service utilization between care settings providing treatment for SUD or other chronic medical conditions. Methods: Participants at two outpatient clinics, addiction medicine (women n = 91, men n = 75) and primary care (women n = 59, men n = 50), completed a one-time electronic survey between July and September 2019. Separately for men and women, comparisons between addiction medicine and primary care groups were made using Pearson χ2, Fisher’s Exact, and T-tests. Results: Participants were 75.0% Black and aged 49.4 years. Overall, unmet RSH needs were less prevalent among participants at the primary care than the addiction medicine clinic, such as receipt of a past 12-month sexual exam (men: 36.0% vs. 17.3%; women: 55.6% vs. 30.1%). The most common barrier to RSH service receipt was cost (men: 59.4%; women: 52.6%), followed by fear of judgment for drug/alcohol use for SUD participants (men: 33% vs. 12%; women: 26% vs. 7%). Many SUD participants expressed high desire for integrated RSH services into the addiction medicine clinic (men: 51.4%; women: 59.8%). Conclusion/Implications: The integration of RSH into addiction medicine is lagging compared to care settings for people with other chronic medical conditions. Future research should focus on advancing sex- and gender-informed RSH service integration into SUD treatment settings.

Delivering Remote Measurement-Based Care in Community Addiction Treatment: Engagement and Usability Over a 6-Month Clinical Pilot.

ObjectiveMeasurement-based care (MBC) is an evidence-based practice in which patients routinely complete standardized measures throughout treatment to help monitor clinical progress and inform clinical decision-making. Despite its potential benefits, MBC is rarely used in community-based substance use disorder (SUD) treatment. In this pilot study, we evaluated the feasibility of incorporating a digital and remotely delivered MBC system into SUD treatment within a community setting by characterizing patients’ and clinicians’ engagement with and usability ratings toward the MBC system that was piloted.MethodsA pilot study was conducted with 30 patients receiving SUD treatment and eight clinicians providing SUD treatment in a large, publicly funded addiction and mental health treatment clinic. Services as usual within the clinic included individual psychotherapy, case management, group therapy, peer support, and medication management for mental health and SUD, including buprenorphine. Patients who enrolled in the pilot continued to receive services as usual and were automatically sent links to complete a 22-item questionnaire, called the weekly check-in, via text message or email weekly for 24 weeks. Results of the weekly check-in were summarized on a clinician-facing web-based dashboard. Engagement was characterized by calculating the mean number of weekly check-ins completed by patients and the mean number times clinicians logged into the MBC system. Ratings of the MBC system’s usability and clinical utility were provided by patients and clinicians.ResultsPatient participants (53.3% male, 56.7% white, 90% Medicaid enrolled) completed a mean of 20.60 weekly check-ins (i.e., 85.8% of the 24 expected per patient). All but one participating clinician with a patient enrolled in the study logged into the clinician-facing dashboard at least once, with an average of 12.20 logins per clinician. Patient and clinician ratings of usability and clinical utility were favorable: most patients agreed with statements that the weekly check-in was easy to navigate and aided self-reflection. All clinicians who completed usability questionnaires agreed with statements indicating that the dashboard was easy to navigate and that it provided meaningful information for SUD treatment.ConclusionsA digital and remotely delivered MBC system can yield high rates of patient and clinician engagement and high ratings of usability and clinical utility when added into SUD treatment as usual. The success of this clinical pilot may be attributable, in part, to the user-centered design processes that were used to develop and refine the MBC system that was piloted. Future efforts may focus on strategies to test whether MBC can be sustainably implemented and offers clinical benefits to patients in community SUD treatment settings.

Symposium

Motivation for change is an important first step in treating substance use disorders (SUDs). Motivation relates to the probability that a person will enter into, continue, and adhere to a specific change strategy. Once viewed as an unmodifiable function of personality traits, motivation today is viewed as multidimensional, dynamic, and modifiable by specific clinician interventions. The transtheoretical model (TTM) and self-determination theory (SDT) are two major theoretical frameworks that explain the motivation for change. Major assessment scales and clinical guidelines base the assessment of motivation on these constructs. However, these models themselves are insufficient in portraying this multifaceted phenomenon. The assessment of motivation is complex and requires an understanding of the client and his circumstances. It runs parallel to efforts to enhance it and is often influenced by the counsellor’s style.Any clinical strategy that enhances client motivation for change is a motivational intervention (MI). Such interventions can include counselling, assessment, and feedback. They can occur over multiple sessions or during one brief intervention, and they can be used in specialty SUD treatment settings or other healthcare settings. MI comprises of multi-element approach including FRAMES, decisional balancing, developing discrepancy, flexible pacing, and maintaining contact with clients. MI is the most widely used approach in SUD treatment.This symposium is an overview of motivational counselling approaches. It describes elements of effective motivational counselling approaches, including FRAMES, and provides an overview of the spirit of MI, the principles of person-centered counselling, the core counselling skills, and the four processes of MI. We will discuss strategies physicians can use to help clients raise doubt and concern about their substance use and move toward contemplating the possibility of change, increase commitment to change, and focus on how and when to develop change plans with clients. Finally, we will be addressing strategies to help them maintain the gains they have made by stabilizing change.

Characterizing autistic traits in treatment-seeking young adults with substance use disorders.

Recent work highlights an increase in the overlap of autism spectrum disorder (ASD) and substance use disorder (SUD). Little is known about the presence of ASD symptoms in SUD-treatment-seeking populations. The informant-rated Social Responsiveness Scale-2 (SRS-2) was completed at intake to an outpatient SUD clinic for youth aged 16-26 (N = 69). Comparisons were made between those with elevated SRS-2 scores on demographic, psychiatric, and substance use variables. Parents of sixty-nine patients with SUD completed the SRS-2. Fourteen (20%) (average age 18.7 ± 2.5) had elevated SRS-2 Total T-scores (≥66) and 55 (average age 18.1 ± 2.8) had non-clinical SRS-2 Total T-scores. There were few differences between groups; however, those with elevated SRS-2 Total T-scores were more likely to have a stimulant use disorder (odds ratio [OR] = 7.59, 95% confidence interval [CI] = 0.77, 101.88; p = 0.05) or an opioid use disorder (OR = 5.02, 95% CI = 0.59, 43.27; p = 0.08) than patients with normal SRS-2 Total T-scores as well as alcohol use in the week prior to intake. A significant proportion of treatment-seeking SUD outpatients suffer from clinically elevated autistic traits. These findings highlight the importance of assessing for autistic traits in SUD treatment settings yet additional research is needed to determine if these findings are specific to the presence of ASD or secondary to sequelae of specific SUD presentations. This study is, to our knowledge, the first to have examined the prevalence, morbidity, or clinical characteristics, associated with ASD symptoms in a SUD-specific population.

Social Work Care in Traumatic Brain Injury and Substance Use Disorder Treatment: A Capacity-Building Model.

Co-occurring traumatic brain injury (TBI) and substance use disorders (SUD) are a major public health concern, yet TBI is often underrecognized within SUD treatment organizations. Social workers in these organizations are well positioned to deliver tailored treatment, but little is known about what social workers are doing to address the needs of these clients. The purpose of this study was to examine current social work practices in providing care to clients with co-occurring TBI and SUD. Using grounded theory methodology, authors conducted semistructured interviews with 17 licensed social workers employed in various SUD treatment settings. Transcript coding was conducted through an iterative process and data were analyzed using NVivo (version 12.0). Results demonstrated that social workers lack basic knowledge on the relationship between TBI and SUD. Additional barriers to providing care included lack of skills to identify history of TBI, lack of community resources, poor agency collaboration, and access-to-care restrictions. Social workers identified their primary roles as advocacy, care coordination, and serving on multidisciplinary teams. These results informed development of a capacity-building model, with recommendations for social work situated in each level of the socioecological framework. This study has important implications for building workforce capacity and collaborative care systems to improve client outcomes.

What do clinicians want? Understanding frontline addiction treatment clinicians\u2019 preferences and priorities to improve the design of measurement-based care technology

BackgroundMeasurement-based care (MBC) is the practice of routinely administering standardized measures to support clinical decision-making and monitor treatment progress. Despite evidence of its effectiveness, MBC is rarely adopted in routine substance use disorder (SUD) treatment settings and little is known about the factors that may improve its adoptability in these settings. The current study gathered qualitative data from SUD treatment clinicians about their perceptions of MBC, the clinical outcomes they would most like to monitor in MBC, and suggestions for the design and implementation of MBC systems in their settings.MethodsFifteen clinicians from one publicly-funded and two privately-funded outpatient SUD treatment clinics participated in one-on-one research interviews. Interviews focused on clinicians’ perceived benefits, drawbacks, and ideas related to implementing MBC technology into their clinical workflows. Interviews were audio recorded, transcribed, and coded to allow for thematic analysis using a mixed deductive and inductive approach. Clinicians also completed a card sorting task to rate the perceived helpfulness of routinely measuring and monitoring different treatment outcomes.ResultsClinicians reported several potential benefits of MBC, including improved patient-provider communication, client empowerment, and improved communication between clinicians. Clinicians also expressed potential drawbacks, including concerns about subjectivity in patient self-reports, limits to personalization, increased time burdens, and needing to learn to use new technologies. Clinicians generated several ideas and preferences aimed at minimizing burden of MBC, illustrating clinical changes over time, improving ease of use, and improving personalization. Numerous patient outcomes were identified as “very helpful” to track, including coping skills, social support, and motivation for change.ConclusionsMBC may be a beneficial tool for improving clinical care in SUD treatment settings. MBC tools may be particularly adoptable if they are compatible with existing workflows, help illustrate gradual and nonlinear progress in SUD treatment, measure outcomes perceived as clinically useful, accommodate multiple use cases and stakeholder groups, and are framed as an additional source of information meant to augment, rather than replace, existing practices and information sources.

Al-Anon Intensive Referral (AIR): A qualitative formative evaluation for implementation

IntroductionThe Al-Anon mutual-help program helps concerned others (COs; e.g., families, friends) of persons with excessive alcohol use. Despite widespread availability of Al-Anon meetings, participation is limited and little is known about how to best facilitate engagement. Al-Anon Intensive Referral (AIR) was developed to facilitate COs' engagement in Al-Anon and is being tested in a randomized controlled trial (RCT). Toward the end of the recruitment for the RCT, a qualitative formative evaluation was conducted to learn about facilitators, barriers, and recommendations for AIR implementation in substance use disorder (SUD) treatment clinics. MethodsThirty-one directors and staff at ten VA and community SUD clinics were interviewed. Semi-structured interviews were based on the Consolidated Framework for Implementation Research and were thematically analyzed to identify facilitators, barriers, and recommendations for AIR implementation. ResultsPerceived facilitators of AIR implementation included AIR's face validity, adaptability, and alignment with staff values and skills, requiring only minimal training. Several interviewees in community settings thought AIR would fit with their current practices (e.g., family groups), and some clinics reported having sufficient staff available for delivering AIR. Perceived barriers included limited staff time, and VA clinics having limited resources for providing services to COs. Furthermore, many clients have no COs, or COs who are unwilling or unable to engage with them. Recommendations included fitting AIR within existing workflows and focusing on COs with highest readiness to receive support. Interviewees also thought AIR could be adapted to a website format or smartphone app, which may expand its reach while decreasing staff burden and cost; however, it may not be as effective and appealing to some demographic groups (e.g., older COs). ConclusionsAIR has strong potential for implementation in SUD treatment settings, but clinics vary on implementation capacity. Most clinics could implement AIR partially (e.g., case-by-case basis) while clinics with sufficient capacity (e.g., staff time) could implement it more fully. These findings can also inform implementation of other interventions for concerned others.

Randomized controlled trial of group motivational interviewing for veterans with substance use disorders

BackgroundMotivational interviewing delivered in a group format is understudied yet promising as a treatment for substance use disorders (SUD). We evaluated the efficacy of group motivational interviewing (GMI) relative to a treatment-control (TCC) for enhancing treatment and self-help engagement and decreasing alcohol and drug use among veterans with SUD and co-existing psychiatric disorders. MethodVeterans (n = 118) with alcohol use disorder were recruited within an outpatient SUD treatment program and randomized to GMI or TCC upon program entry. Alcohol use, SUD treatment, and 12-step session attendance were primary outcomes. Drug use days was the secondary outcome. Participants were assessed at baseline and at one-and three-month follow-up. ResultsSignificant differences were observed between GMI and TCC for binge drinking at both one (RR = .74; 95 % CI [.58, .94]) and three-month follow-up (RR = .74; 95 % CI [.59, .91]). At three-month follow-up, significant differences between treatment conditions were observed for alcohol use days (RR = .79; 95 % CI [.67, .94]), number of SUD treatment sessions (RR = 2.53; 95 % CI [1.99, 3.22]), and 12-step sessions attended (RR = 1.64; 95 % CI [1.35–1.98]). Similarly, we observed significant effects for GMI on reducing alcohol consumption in standard drinks (RR = .49; 95 % CI [.25, .95]). Drug use days declined at each follow-up, with no significant differences between treatment conditions. ConclusionsGMI delivered at SUD treatment program entry enhanced treatment session and 12-step group attendance and lowered alcohol consumption among outpatient Veterans. Future research should study how GMI works and its effectiveness in SUD treatment settings.

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

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

The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs

BackgroundCo-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes. MethodsWe estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013–2014, n = 660, and 2016–2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation. ResultsThe adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%). ConclusionAvailability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.