US Substance Abuse Research Articles

Earmarked Taxes for Mental Health Services in the United States: A Local and State Legal Mapping Study.

State and local governments have been adopting taxes that earmark (i.e., dedicate) revenue for mental health. However, this emergent financing model has not been systematically assessed. We sought to identify all jurisdictions in the United States with policies earmarking taxes for mental health services and characterize attributes of these taxes. A legal mapping study was conducted. Literature reviews and 11 key informant interviews informed search strings. We then searched legal databases (HeinOnline, Cheetah tax repository) and municipal data sources. We collected information on the year the tax went into effect, passage by ballot initiative (yes/no), tax base, tax rate, and revenue generated annually (gross and per capita). We identified 207 policies earmarking taxes for mental health services (95.7% local, 4.3% state, 95.7% passed via ballot initiative). Property taxes (73.9%) and sales taxes/fees (25.1%) were most common. There was substantial heterogeneity in tax design, spending requirements, and oversight. Approximately 30% of the US population lives in a jurisdiction with a tax earmarked for mental health, and these taxes generate over $3.57 billion annually. The median per capita annual revenue generated by these taxes was $18.59 (range = $0.04-$197.09). Per capita annual revenue exceeded $25.00 in 63 jurisdictions (about five times annual per capita spending for mental health provided by the US Substance Abuse and Mental Health Services Administration). Policies earmarking taxes for mental health services are diverse in design and are an increasingly common local financing strategy. The revenue generated by these taxes is substantial in many jurisdictions.

The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

ABSTRACT Background Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. Objective To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. Methods A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. Results Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. Conclusions Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.

The Role of the Household in Prescription Opioid Safety

Invited commentary: Although the US has seen a decrease in opioid misuse rates among adolescents and young adults since 2015, opioid use disorder and overdose remain major public health problems in this high-risk population. Data from the US Substance Abuse and Mental Health Services Administration estimate that in 2018, 5.6% of young adults aged 18 to 25 years and 2.8% of adolescents aged 12 to 17 years misused prescription opioids in the past year.1 The reasons for high substance use rates in this age group are complex but include many factors rooted in neurodevelopment, socioeconomic characteristics, peer groups, and family life.........

Facility-level, state, and financial factors associated with changes in the provision of smoking cessation services in US substance abuse treatment facilities: Results from the National Survey of Substance Abuse Treatment Services 2006 to 2012

Cigarette smoking is common among patients in substance abuse treatment. Tobacco control programs have advocated for integrated tobacco dependence treatment into behavioral healthcare, including within substance abuse treatment facilities (SATFs) to reduce the public health burden of tobacco use. This study used data from seven waves (2006 to 2012) of the National Survey of Substance Abuse Treatment Services (n=94,145) to examine state and annual changes in the provision of smoking cessation services within US SATFs and whether changes over time could be explained by facility-level (private vs public ownership, receipt of earmarks, facility admissions, acceptance of government insurance) and state-level factors (cigarette tax per pack, smoke free policies, and percent of CDC recommended tobacco prevention spending). Results showed that the prevalence of SATFs offering smoking cessation services increased over time, from 13% to 65%. The amount of tax per cigarette pack, accepting government insurance, government (vs private) ownership, facility admissions, and CDC recommended tobacco prevention spending (per state) were the strongest correlates of the provision of smoking cessation programs in SATFs. Facilities that received earmarks were less likely to provide cessation services. Adult smoking prevalence and state-level smoke free policies were not significant correlates of the provision of smoking cessation services over time. Policies aimed at increasing the distribution of tax revenues to cessation services in SATFs may offset tobacco-related burden among those with substance abuse problems.

Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice.

This paper describes the major findings and public health implications of a cross-site evaluation of a national Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program funded by the US Substance Abuse and Mental Health Services Administration (SAMHSA). Eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5years to promote the adoption and sustained implementation of SBIRT. The SBIRT cross-site evaluation used a multi-method evaluation design to provide comprehensive information on the processes, outcomes and costs of SBIRT as implemented in a variety of medical and community settings. SBIRT programs in the two evaluated SAMHSA cohorts screened more than 1million patients/clients. SBIRT implementation was facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Although the quasi-experimental nature of the outcome evaluation does not permit causal inferences, pre-post differences were clinically meaningful and statistically significant for almost every measure of substance use. Greater intervention intensity was associated with larger decreases in substance use. Both brief intervention and brief treatment were associated with positive outcomes, but brief intervention was more cost-effective for most substances. Sixty-nine (67%) of the original performance sites adapted and redesigned SBIRT service delivery after initial grant funding ended. Four factors influenced SBIRT sustainability: presence of program champions, availability of funding, systemic change and effective management of SBIRT provider challenges. The US Substance Abuse and Mental Health Services Administration's Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs. SBIRT is an innovative way to integrate the management of substance use disorders into primary care and general medicine. Screening, Brief Intervention and Referral to Treatment implementation was associated with improvements in treatment system equity, efficiency and economy.

Substance use outcomes of patients served by a large US implementation of Screening, Brief Intervention and Referral to Treatment (SBIRT).

To estimate changes in the substance use behaviors of patients who received services as part of the US Substance Abuse and Mental Health Services Administration's (SAMHSA) Screening, Brief Intervention and Referral to Treatment (SBIRT) grant program. We use a pre-post design and performance monitoring data collected by SBIRT organizations. For a sample of 17 575 patients, we compare pre-SBIRT substance use with substance use 6months after receipt of SBIRT services. SBIRT's correlation with changes in substance use was estimated using generalized linear mixed models to account for the clustering of patients within health-care facility and US state. From pre- to post-SBIRT we found large and statistically significant decreases for almost every measure of substance use. Model-adjusted means indicate that the prevalence of alcohol use was lower 6 months later by 35.6%, heavy drinking by 43.4% and illicit drug use by 75.8%. Greater intervention intensity was associated with larger decreases in substance use. The study design does not support causal conclusions and estimated decreases in reported substance use are due, at least in part, to a well-known set of confounders and natural substance use patterns that may be unrelated to any particular SBIRT intervention. Compared with previously published findings on the Screening, Brief Intervention and Referral to Treatment grant program, our estimates of substance use reduction were smaller, but still consistently large in absolute magnitude and within ranges of estimates from past trials of Screening, Brief Intervention and Referral to Treatment.

Sustaining SBIRT in the wild: simulating revenues and costs for Screening, Brief Intervention and Referral to Treatment programs.

To examine the conditions under which Screening, Brief Intervention and Referral to Treatment (SBIRT) programs can be sustained by health insurance payments. A mathematical model was used to estimate the number of patients needed for revenues to exceed costs. Three medical settings in the United States were examined: in-patient, out-patient and emergency department. Components of SBIRT were delivered by combinations of health-care practitioners (generalists) and behavioral health specialists. Practitioners in seven SBIRT programs who received grants from the US Substance Abuse and Mental Health Services Administration (SAMHSA). Program costs and revenues were measured using data from grantees. Patient flows were measured from administrative data and adjusted with prevalence and screening estimates from the literature. SBIRT can be sustained through health insurance reimbursement in out-patient and emergency department settings in most staffing mixes. To sustain SBIRT in in-patient programs, a patient flow larger than the national average may be needed; if that flow is achieved, the range of screens required to maintain a surplus is narrow. Sensitivity analyses suggest that the results are very sensitive to changes in the proportion of insured patients. Screening, Brief Intervention and Referral to Treatment programs in the United States can be sustained by health insurance payments under a variety of staffing models. Screening, Brief Intervention and Referral to Treatment programs can be sustained only in an in-patient setting with above-average patient flow (more than 2500 screens). Screening, Brief Intervention and Referral to Treatment programs in out-patient and emergency department settings can be sustained with below-average patient flows (fewer than 125 000 out-patient visits and fewer than 27 000 emergency department visits).

Screening, Brief Intervention and Referral to Treatment (SBIRT): rationale, program overview and cross‐site evaluation

Since 2003, the US Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SAMHSA, CSAT) has awarded 32 Screening, Brief Intervention and Referral to Treatment (SBIRT) grants to states, territories and tribal organizations to enhance services for persons with, or at risk for, substance use disorders. The grants supported an expansion of the continuum of care to include screening, brief intervention, brief treatment and referral to treatment in general medical and community settings. This paper describes the SAMHSA SBIRT program in the context of the scientific research that motivated its development, as well as the two cross-site evaluations that are the subject of subsequent papers in this Supplement. A narrative review of research evidence pertaining to SBIRT and of the cross-site evaluation design that made it possible to determine whether the SAMHSA SBIRT grant program achieved its intended aims. The 11 programs within the two cohorts of grant recipients that were the subject of the cross-site evaluations are described in terms of SBIRT service components, performance sites, providers, management structure/activities and patient/client characteristics. The US SAMHSA SBIRT program is an effective way to introduce a variety of new services that extend the continuum of care for substance-involved individuals, ranging from early intervention with non-dependent substance users to referral of more serious cases to specialized substance abuse treatment.

From School Psychology to Disaster Recovery: A Journey of Encountering Resilience and Continually Being Surprised by Peoples’ Own solutions. an Interview With Cynthia K. Hansen*

Dr. Cynthia Hansen, a clinical psychologist, has more than 25 years’ experience as a Solution-Focused practitioner in a variety of settings - from seeing children, adolescents and families in a “typical” therapy setting to field work in response to disasters such as Typhoon Pongsona, 9/11 and Hurricane Katrina. She is currently working in the Office of the Assistant Secretary for Health after serving eight years with the Office of the Assistant Secretary for Preparedness and Response in the US Department of Health and Human Services and was previously Special Advisor on Suicide Prevention with the US Substance Abuse and Mental Health Services Administration {SAMHSA). I invited Cynthia to reflect on her Solution-Focused journey.

Drug-Resistance Strategies of Early Adolescents in Mexico: Gender Differences in the Influence of Drug Offers and Relationship to the Offeror

ABSTRACTTo address increases in substance use among Mexican adolescents, particularly females, US prevention programs are being adapted to the Mexican cultural context. Understanding how responses to substance offers by Mexican adolescents are shaped by gender and relationships to those making offers is an important step in the adaptation process. Using data from Guadalajara, Mexico middle schools (N = 431), this pilot study tested for gender differences in the use of several drug resistance strategies commonly taught in US substance abuse prevention interventions. Results indicated that the drug-resistance strategies of Mexican early adolescents differ by gender, type of substance offered, and the youth's relationship to the offeror. Contrary to previous research on older Mexican adolescents, in this sample, females received more substance offers from age peers than males did, and employed a wider repertoire of drug-resistance strategies, including active strategies such as direct refusals. Gender differences in use of the strategies persisted after controlling for number of offers received. There were gender differences in the conditional effects of greater exposure to offers. A larger volume of alcohol and cigarette offers predicted females' use of direct strategies more strongly than for males, but less strongly than males for marijuana offers. Females' use of drug resistance strategies was more strongly associated with offers from family adults, siblings, and cousins, while males' use of strategies was predicted more strongly by offers from nonfamily adults. Interpretations and prevention implications are discussed in light of changing gender norms in Mexico and gendered patterns of substance use.

Sustainability of State-Level Substance Abuse Prevention Infrastructure After the Completion of the SPF SIG.

Recent national substance abuse prevention efforts that have been disseminated at the state level have provided fertile ground for addressing the dearth of systematic research on state-level substance abuse prevention infrastructure. The Strategic Prevention Framework State Incentive Grant Program (SPF SIG), a national public health initiative sponsored by the US Substance Abuse and Mental Health Services Administration and its Center for Substance Abuse Prevention, is one such effort, providing an opportunity to examine state-level substance abuse prevention infrastructure across the country. The aims of the SPF SIG initiative include reducing substance abuse and its related problems, as well as enhancing state and local prevention infrastructure and capacity. In this article, we describe the status of state-level substance abuse prevention infrastructure and capacity 1 year after the first 26 funded states ended their projects, based on follow-up interviews with state prevention decision-makers. We found that, in five of the six prevention domains we measured, prevention infrastructure capacity increased during the 12-month period after the grants ended. The evidence for further SPF capacity development even after the conclusion of the grants suggests that states recognized the benefits of using the SPF and took deliberate steps to sustain and enhance the integration of this framework into their state prevention systems. In addition, the findings suggest that state agencies and organizations can benefit from time-limited resources aimed at increasing their capacity and that such efforts can have a lasting impact on measures of state prevention system capacity.

Morphine and codeine in oral fluid after controlled poppy seed administration.

Opiates are an important drug class in drug testing programmes. Ingestion of poppy seeds containing morphine and codeine can yield positive opiate tests and mislead result interpretation in forensic and clinical settings. Multiple publications evaluated urine opiate concentrations following poppy seed ingestion, but only two addressed oral fluid (OF) results; neither provided the ingested morphine and codeine dosage. We administered two 45 g raw poppy seed doses, each containing 15.7 mg morphine and 3.1 mg codeine, 8 h apart to 17 healthy adults. All OF specimens were screened by on-site OF immunoassay Draeger DrugTest 5000, and confirmed with OF collected with Oral-Eze® device and quantified by liquid chromatography-tandem mass spectrometry (1 µg/L morphine and codeine limits of quantification). Specimens (n = 459) were collected before and up to 32 h after the first dose. All specimens screened positive 0.5 h after dosing and remained positive for 0.5-13 h at Draeger 20 µg/L morphine cut-off. Maximum OF morphine and codeine concentrations (Cmax ) were 177 and 32.6 µg/L, with times to Cmax (Tmax ) of 0.5-1 h and 0.5-2.5 h post-dose, respectively. Windows of detection after the second dose extended at least 24 h for morphine and to 18 h for codeine. After both doses, the last morphine positive OF result was 1 h with 40 µg/L 2004 proposed US Substance Abuse and Mental Health Services Administration cut-off, and 0.5 h with 95 µg/L cut-off, recently recommended by the Driving under the Influence of Drugs and Medicines project. Positive OF morphine results are possible 0.5-1 h after ingestion of 15.7 mg of morphine in raw poppy seeds, depending on the cut-off employed.

Program- and service-level costs of seven screening, brief intervention, and referral to treatment programs.

This paper examines the costs of delivering screening, brief intervention, and referral to treatment (SBIRT) services within the first seven demonstration programs funded by the US Substance Abuse and Mental Health Services Administration. Service-level costs were estimated and compared across implementation model (contracted specialist, inhouse specialist, inhouse generalist) and service delivery setting (emergency department, hospital inpatient, outpatient). Program-level costs were estimated and compared across grantee recipient programs. Service-level data were collected through timed observations of SBIRT service delivery. Program-level data were collected during key informant interviews using structured cost interview guides. At the service level, support activities that occur before or after engaging the patient comprise a considerable portion of the cost of delivering SBIRT services, especially short duration services. At the program level, average costs decreased as more patients were screened. Comparing across program and service levels, the average annual operating costs calculated at the program level often exceeded the cost of actual service delivery. Provider time spent in support of service provision may comprise a large share of the costs in some cases because of potentially substantial fixed and quasifixed costs associated with program operation. The cost structure of screening, brief intervention, and referral to treatment is complex and discontinuous of patient flow, causing annual operating costs to exceed the costs of actual service provision for some settings and implementation models.

Using customer-focused research and design to build a self-service online store: a case study

American government information centers need to be responsive to an increasingly customer driven information environment while ensuring the sustainability of operations. Enhanced self-service options offer one avenue for addressing both of these needs. This article presents a case study of how the US Substance Abuse and Mental Health Services Administration used extensive stakeholder research and a customer-centric design to reframe its service model by building a self-service online store that integrates access to more than 1300 behavioral health publications previously housed in two separate clearinghouses. The redesigned Substance Abuse and Mental Health Services Administration Store offers users a modern e-commerce website that not only helps customers find, order, download, and share products, but also encourages serendipitous content exploration, which has led to increased orders containing both substance abuse and mental health publications.

Integration of Parenting Skills Education and Interventions in Addiction Treatment

Children of parents with substance use disorders are at risk for various adverse outcomes, and maladaptive parenting behaviors seem to be an important mediator of this risk. Although numerous research studies have highlighted the promise of parenting interventions in modifying parenting behavior, very little is known about the integration of parenting skills education and interventions into addiction treatment programs. In this study, a convenience sample of 125 addiction treatment programs in the United States was drawn. A key staff member was interviewed to gather basic information about the extent and nature of parenting skills education and interventions offered at their program. In addition, respondents were asked to rate the importance of parenting skills relative to other addiction treatment priorities. Descriptive analyses revealed that 43% reported some form of parenting classes, but few used a structured curriculum. Given the known beneficial influence of effective parenting practices on reducing adverse childhood outcomes, it is surprising that relatively few substance abuse treatment programs have adopted structured parenting skills interventions as part of their standard service offerings. More research is warranted on the extent to which parenting skills interventions are integrated into the continuum of services available to parents with a substance use disorder.

Training health-care practitioners in screening, brief intervention, and referral to treatment using standardized approaches and expert coaching

Skill acquisition and maintaining fidelity to a practice requires ongoing monitoring and performance feedback in addition to initial training. This paper describes an evaluation of a training and coaching model employed for the Texas and Georgia screening, brief intervention, and referral to treatment (SBIRT) programs, funded by the US Substance Abuse and Mental Health Services Administration. Both programs were both implemented in large community medical settings that included hospital emergency departments, trauma and inpatient services, and primary care. We describe the specialist training processes with an emphasis on our web- and phone-based expert coaching model and standardized training programs. Specialists who received the multifaceted training package demonstrated significant improvements in SBIRT skills during a half-day standardized patient activity and over 12 months of coaching as measured by the Motivational Interviewing Treatment Integrity (MITI) coding system and coaching evaluations. Videotaped recordings of four standardized patient training sessions for 20 randomly selected trainees were coded by an expert external coder using the MITI-3 coding system. Trainees made significant improvements in evocation (p = 0.004), collaboration (p = 0.003), direction (p = 0.030), empathy (p = 0.029), spirit (p = 0.008), and in percentage of MI-adherent speech (p = 0.035). Further, 148 quarterly reports were examined for those trainees who received at least 12 months of coaching. Thirty-seven trainees (17 from Texas and 20 from Georgia) were included in these analyses. Trainee global ratings on spirit (Texas, p = 0.026; Georgia, p = 0.002) and empathy (Texas, p = 0.012; Georgia, p = 0.001) improved during the four quarters. In addition, MI-behavior ratings for both sites showed improvement at some point over the four quarters analyzed (p < 0.05). This study adds evidence to previous findings indicating that progressive feedback and coaching enhance SBIRT skill development.

Consumer models of recovery: can they survive operationalism?

Consumer models of recovery: can they survive operationalism?

Screening, brief intervention, and referral to treatment for alcohol and other drug use among adolescents: evaluation of a pediatric residency curriculum

Alcohol and other drug use and misuse are increasing in pediatric populations. As part of a US Substance Abuse and Mental Health Services Administration resident training grant, we sought to demonstrate the feasibility and effectiveness of initiating screening, brief intervention, and referral to treatment (SBIRT) in a pediatric residency program. We evaluated the efficacy of a training program for all second- and third-year pediatric and/or medicine/pediatric residents in an adolescent medicine rotation located in an urban teaching hospital. Main outcome measures were pre-/post-training knowledge scores, performance of the Brief Negotiated Interview (BNI) as measured by the BNI adherence scale in pre-/post-training standardized patient encounters (SPE), training satisfaction, and tracking of BNI performance. Thirty-four residents were trained (30 in pediatrics and four in medicine/pediatric programs). The mean age of participants was 28 years (range, 25-35 years); 26 (76%) were women. Fifty percent reported 0-5 hours of didactic training in medical school and residency. Thirty-five percent reported that they never had formal or informal teaching regarding alcohol and drug problems in their residency. There was a significant improvement in knowledge scores pre-/post-training (20.5 versus 23.4, p < 0.001) and a significant improvement in BNI adherence scores during SPE (3.1 versus 8.4, p < 0.001). Residents were very satisfied with their training, reporting a score of 1.6 on a scale of one to five (one = very satisfied, five = very dissatisfied). Integrating an SBIRT curriculum into a pediatric residency program is feasible and effective in increasing residents’ knowledge and skills in performing screening and brief interventions among adolescents and young adults.

Supporting access to alcohol and other drug treatment: the Los Angeles County screening, brief intervention, and referral to treatment project for short-term jail detainees

The University of California at Los Angeles Integrated Substance Abuse Program (UCLA ISAP) was contracted to evaluate the Los Angeles County screening, brief intervention, and referral to treatment project (LA SBIRT). This project was funded by the US Substance Abuse and Mental Health Services Administration to provided SBIRT for short-term-stay detainees. Elements of the program include increasing access to care and reducing alcohol and other drug (AOD) use by screening with the Alcohol, Smoking, and Substance Use Involvement Screening Test (ASSIST), which assesses risk of developing problems related to AOD use; performing a motivational brief intervention based on the results of the ASSIST; and, when indicated, referring detainees to a course of brief treatment sessions. The university’s ISAP used the Government Performance and Results Act tool (GPRA) and ASSIST data to describe the population and assess outcomes. They also conducted a process evaluation. According to results, risky alcohol, cannabis, and tobacco use were high in this group. Among all participants who completed the ASSIST, 95% scored either high or moderate risk for at least one substance. Fewer participants reported using all AODs at follow-up than at baseline, and those who used substances reported using all AODs on fewer days at follow-up. Participants also had less involvement with the criminal justice system at follow-up and received more outpatient services. This SBIRT project was a successful collaboration between the greater Los Angeles criminal justice system and substance abuse treatment networks and offered access to treatment for thousands of detainees. A key lesson learned was that conducting the ASSIST in the jail setting decrease dropout from treatment in this transient population. Locating clients for follow-up was extremely difficult, thus, incentives plus tracking and locating are crucial. Staff felt the ASSIST and motivational interviewing was extremely well-suited to this population. The success of this project depends upon ongoing training, supervision, and collaboration among the stakeholders.

Issues and developments on the consumer recovery construct

The consumer recovery model has had increasing influence on mental health practices in the United States, Western Europe, and several other countries. However, adoption of the model has reflected political decisions rather than empirical evidence of the validity of the model or its value for treatment services. The recovery construct is poorly defined, and until recently there has been no reliable and valid measure with which to base a research program. We have developed an empirical measure that is well-suited for both research and clinical applications: the Maryland Assessment of Recovery in Serious Mental Ill-ness (MARS). We briefly describe the MARS and present preliminary data demonstrating that recovery is not a simple by-product of traditional outcome do-mains, but seems to be a distinct construct that may have important implications for understanding consumers with serious mental illness and for evaluating the outcome of treatment programs.