Alliances to disseminate addiction prevention and treatment (ADAPT): A statewide learning health system to reduce substance use among justice-involved youth in rural communities

Prevention of Opioid Use and Disorder Among Youth Involved in the Legal System: Innovation and Implementation of Four Studies Funded by the NIDA HEAL Initiative

Youth involved in the legal system (YILS) experience rates of opioid and substance use disorders (OUD/SUDs) and overdose that is well above those in the general population. Despite the dire need, and the existing programs that focus on treatment of these problems in YILS, research on opioid initiation, and OUD prevention, including feasibility and sustainability, are severely limited. We present four studies testing interventions that, while not necessarily novel as SUD treatments, test novel structural and interpersonal strategies to prevent opioid initiation/OUD precursors: (1) ADAPT (Clinical Trial No. NCT04499079) provides real-time feedback using community-based treatment information system data to create a more effective mental health and SUD treatment cascade to prevent opioid use; (2) HOME (Clinical Trial No. NCT04135703) provides youth experiencing homelessness, including YILS, with direct access to shelter in independent living without prerequisites as an opioid initiation prevention strategy; (3) LeSA (Clinical Trial No. NCT04678960) uses the Trust-Based Relational Intervention® to equip YILS and their caregivers with self-regulatory and communication skills during the transition from secure confinement to reduce opioid initiation/re-initiation; and (4) POST (Clinical Trial No. NCT04901312) tests two interventions integrating interpersonal/drinking and drug refusal skills, case management, and goal setting among YILS in transitioning out of secure detention as opioid initiation prevention strategies. We discuss early implementation barriers and facilitators, including complexities of prevention research with YILS and adaptations due to COVID-19. We conclude by describing anticipated end products, including implementation of effective prevention interventions and integration of data from multiple projects to address larger, multi-site research questions.

How Dissemination and Implementation Science Can Contribute to the Advancement of Learning Health Systems

Many health systems are working to become learning health systems (LHSs), which aim to improve the value of health care by rapidly, continuously generating evidence to apply to practice. However, challenges remain to advance toward the aspirational goal of becoming a fully mature LHS. While some important challenges have been well described (i.e., building system-level supporting infrastructure and the accessibility of inclusive, integrated, and actionable data), other key challenges are underrecognized, including balancing evaluation rapidity with rigor, applying principles of health equity and classic ethics, focusing on external validity and reproducibility (generalizability), and designing for sustainability. Many LHSs focus on continuous learning cycles, but with limited consideration of issues related to the rapidity of these learning cycles, as well as the sustainability or generalizability of solutions. Some types of data have been consistently underrepresented, including patient-reported outcomes and preferences, social determinants, and behavioral and environmental data, the absence of which can exacerbate health disparities. A promising approach to addressing many challenges that LHSs face may be found in dissemination and implementation (D&I) science. With an emphasis on multilevel dynamic contextual factors, representation of implementation partner engagement, pragmatic research, sustainability, and generalizability, D&I science methods can assist in overcoming many of the challenges facing LHSs. In this article, the authors describe the current state of LHSs and challenges to becoming a mature LHS, propose solutions to current challenges, focusing on the contributions of D&I science with other methods, and propose key components and characteristics of a mature LHS model that others can use to plan and develop their LHSs.

Impacts of COVID-19 at the intersection of substance use disorder treatment and criminal justice systems: findings from three states

BACKGROUND

Individuals with substance use disorders (SUD), particularly opioid use disorder (OUD), who are criminal justice-involved are a particularly vulnerable population that has been adversely affected by COVID-19 due to impacts of the pandemic on both the criminal justice and treatment systems. The manuscript presents qualitative data and findings exploring issues related to SUD/OUD treatment among individuals involved in the justice system and the impacts of COVID-19 on these service systems. Qualitative data were collected separately by teams from three different research hubs/sites in Illinois, Indiana, and Kentucky; at each hub, data were collected from justice system personnel (n = 17) and community-level SUD/OUD providers (n = 21). Codes from two hubs were reviewed and merged to develop the cross-hub coding list. The combined codes were used deductively to analyze the third hub's data, and higher-level themes were then developed across all the hubs' data.

RESULTS

Themes reflected the justice and treatment systems' responses to COVID-19, the intersection of systems and COVID-19's impact on providing OUD treatment for such individuals, and the use of telehealth and telejustice.

CONCLUSIONS

Results highlight that despite rapid adaptations made by systems during the pandemic, additional work is needed to better support individuals with OUD who are involved in the justice system. Such work can inform longer-term public health crisis planning to improve community OUD treatment access and linkage for those who are criminal justice-involved.

Legislatively mandated implementation of medications for opioid use disorders in jails: A qualitative study of clinical, correctional, and jail administrator perspectives

BACKGROUND

Individuals with legal involvement and opioid use disorders (OUD) are at an increased risk of overdose and premature death. Yet, few correctional systems provide all FDA approved medications for OUD (MOUD) to all qualifying incarcerated individuals. We report on the implementation of MOUD in seven Massachusetts' jails following a state legislative mandate to provide access to all FDA-approved MOUD and to connect with treatment upon release.

METHODS/PARTICIPANTS

Based on the Exploration, Preparation, Implementation, and Sustainment framework, 61 clinical, corrections, and senior jail administrators participated in semi-structured interviews and focus groups between December 2019 and January 2020. Qualitative analyses focused on external and internal contexts and bridging factors.

FINDINGS

Participants detailed how the outer context (i.e., legislative mandate) drove acceptance of MOUD and assisted with continuity of care. Salient inner context factors included decision-making around administration of agonist medications, staff perceptions and training, and changes to infrastructure and daily routines. Leadership was critical in flattening standard hierarchies and advocating for flexibility. System-based characteristics of incarcerated individuals, specifically those who were pre-sentenced, presented challenges with treatment initiation. Inter- and intra-agency bridging factors reduced duplication of effort and led to quick, innovative solutions.

CONCLUSIONS

Implementation of MOUD in jails requires collaboration with and reliance on external agencies. Preparation for implementation should involve systematic reviews of available resources and connections. Implementation requires flexibility from institutional systems that are inherently rigid. Accordingly, leaders and policymakers must recognize the cultural shift inherent in such programs and allow for resources and education to assure program success.

Engaging the justice system to address the opioid crisis: The Justice Community Opioid Innovation Network (JCOIN)

Many individuals with opioid use disorder come into contact with the justice system each year, making the nexus between the criminal justice system and the health care system a critical juncture for responding to the opioid crisis and simultaneously promoting public health and public safety. Collaborations across these sectors are essential to providing effective screening, treatment, and discharge planning; connecting individuals to services following release; promoting long-term recovery while reducing recidivism; and ultimately bringing the opioid crisis under control. In 2019, with the support of the NIH Helping to End Addiction Long-term (HEAL) Initiative, the National Institute on Drug Abuse launched the Justice Community Opioid Innovation Network (JCOIN). JCOIN is a >$150M multisite cooperative designed to facilitate transdisciplinary collaborations that can create actionable, translatable insights for the justice system and community-based organizations to address the opioid epidemic in justice-involved populations. JCOIN brings together 11 Research Hubs, a coordination and translation center (CTC), and a methodology and advanced analytics resource center (MAARC), with the goal of generating evidence that is greater than the sum of the parts. Collectively, the network will field at least 12 large-scale multisite clinical trials, which are described in this special issue. This article provides a brief overview of the scientific underpinnings for these trials; describes the broad themes connecting them; and discusses the intersections of the JCOIN initiative with the COVID-19 pandemic.