Treating Substance Use Research Articles

A Systematic Review and Narrative Synthesis of Interventions to Address Substance Use Disorders and Other Mental Health Disorders in Prison Settings With a Focus on Low- and Middle-Income Countries

Interventions to treat substance use disorders (SUDs) and other mental health disorders (MHDs) in prison settings vary in both availability and effectiveness across contexts. Furthermore, incomplete characterization of intervention efficacy and/or effectiveness impacts the ability to know whether an intervention with demonstrated effectiveness in one setting will be effective in another setting. We systematically reviewed the literature for studies of interventions for SUDs and other MHDs conducted in prison settings, and synthesized the identified interventions and identified evidence gaps. Search strategies yielded 9,599 articles published between January 1, 2010, and December 31, 2020. A total of 82 articles were identified as eligible with interventions presented for SUDs ( n = 52), for MHDs ( n = 23), and for SUDs/MHDs ( n = 7). Findings point to a narrow range of interventions of demonstrated effectiveness and to important gaps in the evidence-base for which high-quality research, particularly in low- and middle-income settings, is needed.

An fMRI analysis of verbal and non-verbal working memory in people with a past history of opioid dependence.

Working memory describes the ability to maintain and manipulate information held in mind, and it is a fundamental aspect of executive function. Within drug addiction, impairments of executive control over behavior are thought to lead to poor decision making and risky behaviors. Previous research has demonstrated working memory (WM) and executive function difficulties in opioid-dependent individuals, but the neural underpinnings of such impairments in this population are not well understood. This study used functional magnetic resonance imaging to examine the neural mechanisms involved in WM in 13 opioid-dependent, methadone-maintained participants (OP) and 13 matched, healthy controls (HC). A Sternberg item-recognition task was administered with three conditions: (1) a "verbal" condition in which participants determined whether any six visually presented target letters matched a probe item that was presented 4-6 s later, (2) a "non-verbal" condition in which participants were presented with a Chinese character and, following a 4-6 s delay, determined whether the character matched the probe item, and (3) a "control" condition in which participants were presented with three horizontal lines and following the same delay, determined whether the lines matched a probe item (always the same three lines). Functional magnetic resonance imaging (fMRI) contrasts focused on the delay (or "maintenance") phase for verbal and non-verbal conditions relative to the control condition. Accuracy on the WM task did not differ between groups, but the OP group was significantly slower to respond. The fMRI imaging results indicated differences in brain activity between the OP and HC groups. fMRI-guided regions of interest correlated with age of first alcohol and THC use, suggesting that early substance use, in addition to years of opioid-abuse, may have played a role in the OP group's WM performance. A deeper understanding of these neural differences between opioid-dependent individuals and their healthy control counterparts helps shed light on fundamental ways in which substance use impacts the brain and cognition, potentially opening up novel avenues for therapeutic targets to treat substance use disorder.

Influence of Provider and Leader Perspectives about Concurrent Tobacco-Use Care during Substance-Use Treatment on Their Tobacco Intervention Provision with Clients: A Mixed-Methods Study.

People with substance-use disorders have elevated rates of tobacco use compared with the general population, yet rarely receive tobacco-dependence treatment within substance-use treatment settings (SUTS). One barrier to delivering evidence-based interventions in SUTS is providers' misconception that treating tobacco use and non-nicotine substance use concurrently jeopardizes clients' substance-use recovery, although research indicates that it enhances support for recovery and relapse prevention. A total of 86 treatment providers employed in SUTS (i.e., 9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs), 6 substance-use treatment programs in LMHAs, and 55 stand-alone substance-use treatment centers) in Texas, USA, answered survey questions about their (1) thoughts about treating tobacco during substance-use treatment, and (2) delivery of the 5A's tobacco-use intervention (Ask, Advise, Assess, Assist, Arrange). Twenty-six providers and leaders were interviewed about attitudes toward tobacco-free workplace policies and tobacco dependence and the relative importance of treating tobacco (vs. other substance-use disorders) at their center. Providers who did not believe tobacco use should be addressed as soon as clients begin treatment (i.e., endorsed responses of after 1 year, it depends on the client, or never) had lower odds of Asking clients about their tobacco use (OR = 0.195), Advising clients to quit smoking (OR = 0.176), and Assessing interest in quitting smoking (OR = 0.322). Qualitative results revealed barriers including beliefs that clients need to smoke to relieve the stress of substance-use recovery, are disinterested in quitting, fears that concurrent treatment would jeopardize substance use, and limited resources; additional training and education resources was the key facilitator theme. The results demonstrate a critical need to eliminate barriers to tobacco-treatment provision for clients in SUTS through education to correct misperceptions, specialized training to equip providers with knowledge and skills, and resources to build center capacity. Integrating evidence-based smoking interventions into routine care is key to support the recovery efforts of clients in SUTS.

Criminal thinking and psychosocial characteristics among young adults entering residential substance use treatment.

Background and aim: Young adults with substance use (SU) problems face a high risk of co-occurring problems, including criminality. The aim of the present study was to assess the psychosocial characteristics, SU problems, and criminal thinking young adults entering SU treatment have, and whether the SU characteristics, sex and age are associated with criminal thinking scores. Methods: The sample was 407 young adults aged 16-29 years who underwent an entry assessment between January 2011 and December 2016 at a residential SU treatment institution in Norway. All study data were extracted from electronic health records, including survey information from the Achenbach System of Empirically Based Assessment and the Psychological Inventory of Criminal Thinking Styles. Results: In the present sample, severe SU, high rates of psychosocial problems, and criminal thinking were reported. Almost three-quarters (72.67%) of young adults reported high levels of criminal thinking (≥60). However, male participants were more likely to report high levels of criminal thinking compared to female participants (p=0.031). In bivariate regression models, only sex and having stimulants/opioids as primary drug were associated with mean levels of criminal thinking. The same was true in the multiple regression model. Conclusion: Young adults in residential SU treatment are a multi-problem high-risk/high-need group of people. Due to the elevated levels of criminal thinking, we recommend that young adults in SU treatment should be screened for criminogenic treatment needs, such as criminal thinking, regardless of justice involvement.

Synthetic cannabinoids awareness among patients with opioid use disorder in Serbia - A survey based cross-sectional pilot study.

There is limited data on the awareness and use of synthetic cannabinoids (SCs) in high-risk population in Serbia, despite SCs becoming more and more common at illicit drug market. This pilot study aimed to examine the awareness and prevalence of use of SCs in patients with an opioid-use disorder and to identify patient characteristics and other factors associated with SCs use. This cross-sectional study was conducted at the Clinic for Psychiatry, Clinical Center Vojvodina, Serbia, the largest tertiary health care institution in this region of the country. All patients hospitalized due to the treatment of opioid dependence during November and December 2017 were included (response rate 100%), and filled-out an anonymous questionnaire specifically developed for the purpose of this study. Differences between patients reporting SCs use and those who did not were compared using chi-square test with values of p < 0.05 were considered significant. Out of 64 patients (median age 36.37 years), one third (32.81%) reported using SCs. Socio-demographic characteristics of the subjects were not associated with SCs use. There were differences in the most common sources of information reported between the SCs users and non-users. Majority of SCs users (76.0%) were informed about SCs through friends, compared with just 26.0% of non-users (<0.001). Nearly all study participants (93.8%) were daily tobacco users. The share of respondents reporting alcohol and marihuana use was significantly higher among the SCs users (52.0% vs. 20.9%, p = 0.011 and 15.6% vs. 12.5%, p = 0.015), respectively. Higher share of SCs users used multiple psychoactive substances (38.1% vs. 16.3%), and this difference was statistically significant (p = 0.047). The most commonly reported adverse effect of SCs among users included dry mouth (81.0%), trouble thinking clearly (52.4%) and panic attacks (52.4%). Understanding the awareness and use of SCs among high-risk drug users, as well as associated factors can help improve substance-use disorder treatment in our setting. Educational activities targeting public are urgently needed to raise awareness on SCs, considering that social contacts are the main sources of information on SC for this vulnerable population. Users of SCs have also reported using other psychoactive substances more often, and this calls for a holistic approach addressing multiple factors to improve substance-use treatment in our setting.

Treating addiction with deep brain stimulation: Ethical and legal considerations.

The use of neuromodulation in the treatment of psychiatric conditions is controversial despite its lengthy history. This particularly applies to the use of invasive neuromodulation, such as deep brain stimulation (DBS), to treat substance use disorder (SUD) due to the considerable risks of the procedures. However, given the advances in DBS research and the shortcomings of current treatment modalities for addiction, off-label use and clinical trials are being implemented for the management of treatment-refractory patients. Here we conduct an ethical and legal analysis of DBS for SUD, referencing the four foundational principles of medical ethics and key legal concepts. There are major concerns related to the capacity of a SUD patient to provide informed consent, as well as the risks and benefits of DBS compared to traditional treatment methods. In addition to ethical concerns, we explore potential legal issues that may arise from DBS in the treatment of addiction. These include the potential mandate of these procedures in the context of the criminalization of substance use, and the issue of familial consent in the decision-making process. Given the paucity of relevant clinical guidelines or legal cases, general medico-legal principles serve as the reference in making decisions about the responsible use of DBS as a treatment for addiction. Given the rapidly increasing evidence for DBS as a treatment for SUD, it is an urgent imperative to consider the relevant key ethical and legal issues. Incorporating IDEAL (Idea, Development, Exploration, Assessment, Long-term follow-up) framework into future research in DBS is recommended to evaluate patient safety and ethical perspectives. With the broad criminalization of SUD across the globe, legal coercion of DBS is not impossible, especially if proven to be effective to treat SUD. It is advised for stakeholders to urgently consider incorporating DBS-related drug policies so that the potential benefits of DBS within the rights of people with SUD are not hindered by the lack of clinical guidance and legislations.

A meta‐analysis of neurofeedback for treating substance use disorders

AbstractA meta‐analysis was conducted to assess the efficacy of neurofeedback (NFB) in the treatment of individuals with substance use disorder (SUD) in between‐group studies. This study reports findings from the first exhaustive search of the literature on the topic and included articles selected from a total of 58 databases/repositories. Studies were evaluated using Hedge's g as the effect size measure and were assessed for risk of bias using funnel plot, Fail‐Safe N, and Trim and Fill analysis. Ten studies, containing 30 effect sizes were evaluated to determine the overall efficacy of NFB for decreasing symptoms of SUD (N = 397), yielding a mean effect size of g = –1.49 (CI 95 = –1.95, –1.03; PI 95 = –4.37 to 1.39). This meta‐analysis provides strong evidence for the efficacy of NFB in treating SUD while also highlighting the value of wholistic client care in SUD treatment.

In Case You Haven't Heard…

Drugs were a topic, of course, in President Biden's State of the Union (SOTU) speech on Feb. 7. Not only did he refer to past efforts of his administration, but to hopeful changes for the future, noting correctly that indeed, treating substance use issues is not political. Rahul Gupta, M.D., director of the Office of National Drug Control Policy, issued a statement that night. Gupta touted removal of the X‐waiver for buprenorphine (see ADAW https://onlinelibrary.wiley.com/doi/10.1002/adaw.33651) as the main factor in making treatment more accessible. “The overdose epidemic is not a red state problem or a blue state problem — it's America's problem and the President has reaffirmed his commitment to continuing our work together to beat this crisis,” he said. Gupta added that, “the President called for removing barriers to treatment, and we have delivered on that, working with Republicans and Democrats in Congress to remove the X‐waiver.” Gupta also cited a reduction in opioid overdose deaths. For a fact sheet from the White House on the SOTU, go to https://www.whitehouse.gov/briefing‐room/statements‐releases/2023/02/07/fact‐sheet‐in‐state‐of‐the‐union‐president‐biden‐to‐outline‐vision‐to‐advance‐progress‐on‐unity‐agenda‐in‐year‐ahead/.

The Role of Pre-Treatment Traumatic Stress Symptoms in Adolescent Substance Use Treatment Outcomes

Background: Prominent theories suggest that individuals with co-occurring traumatic stress symptoms (TSS) and substance use (SU) may be less responsive to SU treatment compared to those with SU only. However, empirical findings in adult samples are mixed, and there has been limited work among adolescents. This study assesses the association between TSS and SU treatment outcomes among trauma-exposed adolescents, using statistical methods to reduce potential confounding from important factors such as baseline SU severity. Method: 2,963 adolescents with lifetime history of victimization received evidence-based SU treatment in outpatient community settings. At baseline, 3- and 6-months, youth were assessed using the Global Appraisal of Individual Needs Traumatic Stress Scale and the Substance Frequency Scale. Propensity score weighting was used to mitigate potential confounding due to baseline differences in sociodemographic characteristics and SU across youth with varying levels of TSS. Results: Propensity score weighting successfully balanced baseline differences in sociodemographic factors and baseline SU across youth. Among all youth, mean SU was lower at both 3- and 6- month follow-up relative to baseline, indicating declining use. After adjusting for potential confounders, we observed no statistically significant relationship between TSS and SU at either 3- or 6-month follow-up. Conclusions: Based on this investigation, conducted among a large sample of trauma-exposed youth receiving evidence-based outpatient SU treatment, baseline TSS do not appear to be negatively associated with SU treatment outcomes. However, future research should examine whether youth with TSS achieve better outcomes through integrative treatment for both SU and TSS.

Association between substance use treatment motivations and retention in treatment

ABSTRACT Background Identifying factors influencing the retention in the treatment of substance users is one of the great issues in the health field. The present study was performed to identify the motivations to start treatment and their relationship with retention in the treatment. Methods and materials This cross-sectional study carried out on 189 people with substance use disorder undergoing treatment in the first month referred to addiction treatment clinics in 2021. Forty clinics were selected using a simple random sampling method. Required information was collected using a demographic and “motivating factors to quit” questionnaire. Data were analyzed using chi-square, Fisher’s exact and Mann – Whitney U tests through SPSS version 24. Results This study showed a significant relationship between the place of residence and occupation of the subjects with all the fields of the “motivating factors to quit” questionnaire (p < 0.05). Only “family” item had a significant relationship with retention in the treatment (p < 0.05). Conclusion Considering the relationship between the family item and retention in the treatment, it seems that informing the patient’s family about the importance of encouraging, supporting and quit plan can be an effective help in increasing retention in the treatment.

Avoidance self-efficacy: Personal indicators of risky sex and substance use among at-risk youth

Adolescent substance use (SU) is associated with risky sex behavior and sexually transmitted infections and is a risk factor for subsequent risky sex decisions. Based on a sample of 1,580 youth in residential SU treatment, this study investigated how a static factor (race) and two dynamic personal factors (risk-taking, assertiveness) contributed to adolescents’ perceived ability to avoid high-risk SU and sex behavior (avoidance self-efficacy). Results showed that race correlated with risk-taking and assertiveness, with White youth reporting higher ratings of assertiveness and risk-taking. Self-reported assertiveness and risk-taking also predicted SU and risky sex avoidance. This study underscores the importance of race and personal factors in relation to adolescents’ confidence in avoiding high-risk situations.

Depression and Suicidal Behavior Comorbidity in Patients Admitted to Substance-Use Residential Treatment in Aguascalientes, Mexico

ABSTRACT Purpose Epidemiological studies show that depressive and substance use disorders are salient risk factors for suicidal behavior. In residential centers in Mexico City, 75.72% of the patients are diagnosed with comorbidity of substance use and psychiatric disorders; however, the specific prevalence of depression and suicidal behavior in this population has not been reported. This study aims to inform the comorbidity of depression and suicidal behavior in crystal users in residential centers in the state of Aguascalientes, Mexico. Method A brief survey was applied to measure substance use patterns, suicidal behavior, and depression symptoms using the Depression Scale of the Center of Epidemiological Studies (CES-D-R). The sample included 343 participants. Results The results show that of the 23.3% of participants who reported depressive symptoms, 65% showed suicidal ideation, 46% suicide planning, and 43% suicidal attempt. Discussions These results show the importance of implementing components that address depression and suicidal behavior in interventions for substance use. Conclusions Currently, no specialized interventions are developed to treat substance use disorders with crystal methamphetamine and, at the same time, treat others mental problems like depression and suicidal behavior. We conclude that the development of this intervention is necessary and urgent.

The effect of repetitive transcranial magnetic stimulation on electroencephalography microstates of patients with heroin-addiction

The effects of transcranial magnetic stimulation in treating substance use disorders are gaining attention; however, most existing studies used subjective measures to examine the treatment effects. Objective electroencephalography (EEG)-based microstate analysis is important for measuring the efficacy of transcranial magnetic stimulation in patients with heroin addiction. We investigated dynamic brain activity changes in individuals with heroin addiction after transcranial magnetic stimulation using microstate indicators. Thirty-two patients received intermittent theta-burst stimulation (iTBS) over the left dorsolateral prefrontal cortex. Resting-state EEG data were collected pre-intervention and 10 days post-intervention. The feature values of the significantly different microstate classes were computed using a K-means clustering algorithm. Four EEG microstate classes (A–D) were noted. There were significant increases in the duration, occurrence, and contribution of microstate class A after the iTBS intervention. K-means classification accuracy reached 81.5%. The EEG microstate is an effective improvement indicator in patients with heroin addiction treated with iTBS. Microstates were examined using machine learning; this method effectively classified the pre- and post-intervention cohorts among patients with heroin addiction and healthy individuals. Using EEG microstate to measure heroin addiction and further exploring the effect of iTBS in patients with heroin addiction merit clinical investigation.

Integration of Substance Use Disorder Treatment Into a Traditional Community Mental Health Treatment System.

In response to the opioid crisis, Catholic Charities of Baltimore sought to integrate substance use disorder treatment into their outpatient community mental health clinics. The agency developed a systematic practice improvement strategy that included a competency-based curriculum and supervision plan for psychiatric providers and therapists. Psychiatric providers developed competency with medications used to treat substance use disorders, and therapists developed competency in therapeutic modalities to treat substance use disorders, all of which were gradually integrated into outpatient clinics. This column demonstrates that integration of substance use disorder treatment into outpatient community mental health care is feasible and beneficial.

Adherence to e-health interventions for substance use and the factors influencing it: Systematic Review, meta-analysis, and meta-regression.

Substance use disorders affect 36 million people globally, but only a small proportion of them receive the necessary treatment. E-health interventions have been developed to address this issue by improving access to substance use treatment. However, concerns about participant engagement and adherence to these interventions remain. This review aimed to evaluate adherence to e-health interventions targeting substance use and identify hypothesized predictors of adherence. A systematic review of literature published between 2009 and 2020 was conducted, and data on adherence measures and hypothesized predictors were extracted. Meta-analysis and meta-regression were used to analyze the data. The two adherence measures were (a) the mean proportion of modules completed across the intervention groups and (b) the proportion of participants that completed all modules. Four meta-regression models assessed each covariate including guidance, blended treatment, intervention duration and recruitment strategy. The overall pooled adherence rate was 0.60 (95%-CI: 0.52-0.67) for the mean proportion of modules completed across 30 intervention arms and 0.47 (95%-CI: 0.35-0.59) for the proportion of participants that completed all modules across 9 intervention arms. Guidance, blended treatment, and recruitment were significant predictors of adherence, while treatment duration was not. The study suggests that more research is needed to identify predictors of adherence, in order to determine specific aspects that contribute to better exposure to intervention content. Reporting adherence and predictors in future studies can lead to improved meta-analyses and the development of more engaging interventions. Identifying predictors can aid in designing effective interventions for substance use disorders, with important implications for e-health interventions targeting substance use.

Prior Periods of Abstinence Among Adults With an Alcohol Use Disorder: A Qualitative Template Analysis.

Abstaining from substance use is a goal of many people with alcohol use disorder (AUD). Understanding patient perspectives of a period of abstinence may assist persons with AUD in achieving this goal. We accessed the electronic health records of adults with AUD entering an emergency department in Baltimore, Maryland, who received a brief peer support intervention for substance use. Data contained open-ended text entered by staff after a patient indicated ever having a sustained period of substance abstinence. Using qualitative template analysis methodology, we identified codes and themes from these open-ended responses from N = 153 adults with AUD. The sample was primarily male (n = 109, 71.2%) and White (n = 98, 64.1%) with an average age of 43.8 years (SD = 11.2). Themes identified included the abstinence length, abstinence reason, relapse, triggers, time of relapse, and treatment. The most common code for abstinence length was "between 1 and 5 years" (n = 55, 35.9%). Other abstinence length codes included "less than 1 year" and "more than 5 years." Relapse triggers included "family (non-death)," "death of a loved one," "social," "economic," and "treatment-related" reasons. Findings from this study could be used to inform strategies for peer support interventions to assist patients with substance abstinence.

Savoring as an intervention for cannabis use: acceptability, feasibility, and preliminary results

Although savoring appears protective against cannabis problems, researchers have yet to apply it to reduce cannabis-related harms. Study I surveyed a large (N = 557, M age = 36.9, 50.1% Male, 73% White) sample who rated a hypothetical savoring intervention as feasible and acceptable; those who savored more reported fewer cannabis problems, less use, and less intoxication. Study II, a pilot experiment (N = 26, M age = 18, 34.6% Male, 42% White), randomly assigned participants to either a week-long savoring intervention (n = 15) or control group (n = 11). Savorers reported moderate to large decreases across time in cannabis use, amount consumed, and intoxication as well as increases in happiness and negative cannabis expectancies. Both studies suggest that savoring can reduce use and protect against negative outcomes. These preliminary findings suggest that further work to examine the efficacy of savoring as an intervention for substance use appears warranted.

“Remember, we are not White”

Substance abuse and its associated disorders affect a whole spectrum of people. Substance users and individuals affected by substance abuse come from diverse backgrounds with varying beliefs and subscribe to various doctrines. This body of work explores the perspectives of a certain Black rural community in Limpopo Province, South Africa, about substance abuse and its treatment in their neighbourhood. Data was collected from purposively sampled community members aged between 18 and 35 years through a focus group discussion. The participation of the focus group members in the study was voluntary and consented to. The collected data was coded and thematically analysed. Community members ascribe the abuse of substances to different factors such as peer pressure, poverty, and idleness—the most prominent factor, as cited by participants, is witchcraft fueled by jealousy. The youth in the community feel like a failure to maintain sobriety by those admitted to treatment centers is not only due to structural challenges but can also be attributed to the spiritual realm. There is a need to consider service users’ backgrounds and beliefs in substance abuse treatment. The social work value of individualization should be duly applied when working with people who have substance abuse problems. There is also a need to obtain treatment workers’ perspectives about the integrated approach in treating substance use disorders.

Alternative use of suvorexant (Belsomra®) for the prevention of alcohol drinking and seeking in rats with a history of alcohol dependence.

Alcohol use disorder (AUD) is one of the most treatment-resistant medical conditions globally. The orexin (Orx) system regulates diverse physiological processes, including stress, and is a system of interest for the development of pharmaceuticals to treat substance use disorders, particularly AUD. The present study tested the ability of the dual orexin receptor antagonist suvorexant (SUV), marketed by Merck as Belsomra®, for the treatment of insomnia, to decrease alcohol self-administration and the stress-induced reinstatement of alcohol-seeking behavior in male Wistar rats with a history of alcohol dependence. Rats were trained to orally self-administer 10% alcohol (30 min/day for 3 weeks) and were either made dependent via chronic intermittent alcohol vapor exposure (14 h ON, 10 h OFF) for 6 weeks or exposed to air (non-dependent). Starting on week 7, the effect of SUV (0-20 mg/kg, p.o.) was tested on alcohol self-administration at acute abstinence (8 h after vapor was turned OFF) twice weekly. A separate cohort of rats that were prepared in parallel was removed from alcohol vapor exposure and then subjected to extinction training for 14 sessions. Once extinction was achieved, the rats received SUV (0 and 5 mg/kg, p.o.) and were tested for the footshock stress-induced reinstatement of alcohol-seeking behavior. Suvorexant at 5, 10, and 20 mg/kg selectively decreased alcohol intake in dependent rats. Furthermore, 5 mg/kg SUV prevented the stress-induced reinstatement of alcohol-seeking behavior in dependent rats only. These results underscore the significance of targeting the Orx system for the treatment of substance use disorders generally and suggest that repurposing SUV could be an alternative approach for the treatment of AUD.

The comparative effectiveness of Core versus Core+Enhanced implementation strategies in a randomized controlled trial to improve substance use treatment receipt among justice-involved youth

BackgroundMost justice-involved youth are supervised in community settings, where assessment and linkage to substance use (SU) treatment services are inconsistent and fragmented. Only 1/3 of youth with an identified SU need receive a treatment referral and even fewer initiate services. Thus, improving identification and linkage to treatment requires coordination across juvenile justice (JJ) and behavioral health (BH) agencies. The current study examines the comparative effectiveness of two bundled implementation intervention strategies for improving SU treatment initiation, engagement, and continuing care among justice-involved youth supervised in community settings. Exploration, Preparation, Implementation, Sustainment (EPIS) served as the conceptual framework for study design and selection/timing of implementation intervention components, and the BH Services Cascade served as the conceptual and measurement framework for identifying and addressing gaps in service receipt.MethodsPart of a larger Juvenile-Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) Cooperative, this study involved a multisite, cluster-randomized control trial where sites were paired then randomly assigned to receive Core (training teams on the BH Services Cascade and data-driven decision making; supporting goal selection) or Core+Enhanced (external facilitation of implementation teams) intervention components. Youth service records were collected from 20 JJ community supervision agencies (in five states) across five study phases (baseline, pre-randomization, early experiment, late experiment, maintenance). Implementation teams comprised of JJ and BH staff collaboratively identified goals along the BH Cascade and used data-driven decision-making to implement change.ResultsResults suggest that Core intervention components were effective at increasing service receipt over time relative to baseline, but differences between Core and Core+Enhanced conditions were non-significant. Time to service initiation was shorter among Core+Enhanced sites, and deeper Cascade penetration occurred when external facilitation (of implementation teams) was provided. Wide variation existed in the degree and nature of change across service systems.ConclusionsFindings demonstrate the criticality of early EPIS phases, demonstrating that strategies provided during the formative exploration and preparation phases produced some improvement in service receipt, whereas implementation-focused activities produced incremental improvement in moving youth farther along the Cascade.