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This study aims to describe which substance use service (SUS) organizations and who within these organizations support the maintenance of policies targeted at improving substance use treatment services. An online survey assessing respondent, organizational and program demographics, and knowledge and support regarding policy changes was distributed to all certified SUS and harm reduction programs in NYS. Bivariate and latent class analyses were used to identify patterns and associations to policy choices. Across the 227 respondents, there was a support for maintaining expansion of insurance coverage, virtual behavioral health/counseling and medication initiation/maintenance visits, reductions in prior authorizations, and access to prevention/harm reduction services. Three classes of support for policies were derived: (1) high-supporters (n = 49; 21%), (2) low-supporters (n = 66; 29%), and (3) selective-supporters. Having knowledge of policy changes was associated with membership in the high-supporters class. Implications regarding the role of knowledge in behavioral health policies dissemination structures, decision-making, and long-term expansion of SUS are discussed.

Introduction Due to the COVID-19 pandemic, regulations for substance use services changed to accommodate stay-at-home orders and physical distancing guidelines. Methods Using in-depth interviews (N = 14) and framework analysis, we describe how policymakers developed, adopted, and implemented regulations governing services for substance use disorders during COVID-19, and how policymakers' perceived the impacts of these regulations in New York State. Results During the COVID-19 pandemic, policymakers shifted to more inclusive approaches of knowledge generation and co-production of recommendations. Barriers to adoption and implementation of new regulations included medication/services supply, lack of integration, stigma, and overcriminalization. Conclusion Findings from this study highlight the potential feasibility and benefits of co-produced policies for substance use services and the need for consistent service supply, better integration with health care services, reduced stigma, improved funding structures, best practice guidelines, criminal justice reform, and harm reduction support. These considerations should inform future policy maintenance and modifications to substance use services related to COVID-19.

Introduction Project Extension for Community Healthcare Outcomes (ECHO™) is a hub-and-spoke knowledge-sharing network, led by expert teams who use multipoint videoconferencing to conduct virtual clinics with community providers in order to improve the quality of care. For this project, members of the Addiction Technology Transfer Center network applied this model in order to enhance workforce capacity to deliver clinical supervision for the treatment of substance use disorders. Methods Clinical supervisors ( n =66) employed in substance use disorder treatment programs were recruited to participate in this pilot study. The virtual ECHO clinic consisted of 12 total sessions, each lasting 1 hour and comprising a 15-minute mini-lecture on a clinical supervision topic and a 45-minute case presentation and review. All data were collected and analyzed between September 2016 and June 2017. Results Forty-eight staff attended at least one ECHO session (mean=6.38) and results are presented for 20 staff who completed the follow-up survey. Participants were highly satisfied with the overall intervention, organization of the clinic and the facilitation of Hub experts, relevance of the technical assistance to their work, and with the impact of the intervention on their effectiveness as a supervisor. Results also indicate that there were significant self-reported improvements in clinical supervision self-efficacy following participation in the ECHO clinic. Conclusions Results from this pilot study suggest that ECHO virtual clinics are feasible to implement for the purpose of workforce development, are well liked by participants, and can enhance clinical supervision self-efficacy among participants. Further research should explore the impact of self-efficacy on the effective implementation of clinical supervision practices. Supplement information This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Background In 2010, the first comprehensive National HIV/AIDS Strategy for the United States was released and included three goals: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and improving health outcomes for people living with HIV, and (3) reducing HIV-related health disparities and health inequities. In 2013, as part of its effort to help address the National HIV/AIDS Strategy, the National Institute on Drug Abuse (NIDA) funded a type 2 effectiveness-implementation hybrid trial titled the Substance Abuse Treatment to HIV Care (SAT2HIV) Project. Aim 1 of the SAT2HIV Project tests the effectiveness of a motivational interviewing-based brief intervention (MIBI) for substance use as an adjunct to usual care within AIDS Service Organizations (ASOs) as part of its MIBI Experiment. Aim 2 of the SAT2HIV Project tests the effectiveness of implementation and sustainment facilitation (ISF) as an adjunct to the Addiction Technology Transfer Center (ATTC) model for training staff in motivational interviewing as part of its ISF Experiment. The current paper describes the study protocol for the MIBI Experiment. Methods As part of a multisite randomized controlled trial, individuals with comorbid HIV/AIDS and problematic substance use are randomized to receive either the ASOs’ usual care (control condition) or usual care plus a MIBI for substance use (experimental condition) delivered by trained ASO case-management staff. Primary outcome measures are reductions in days of primary substance use, number of substance-related problems, times engaging in risky behaviors, days of non-adherence to HIV medications, and increases in substance use treatment. As part of this paper, we describe the trial protocol in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines. Discussion If successfully able to implement MIBI as an effective adjunct to usual care, the current trial may have a significant impact on increasing the capacity of ASOs to address problematic substance use among individuals living with HIV/AIDS. Reducing the prevalence of problematic substance use among individuals living with HIV/AIDS within the United States may lead to significant improvements on key performance measures (i.e., the HIV Care Continuum and the 90-90-90 target). Trial registration ClinicalTrials.gov: NCT02495402

An implementation approach, featuring direct, onsite technical assistance is described, and findings from a pilot study assessing the capability of Federally Qualified Health Centers to provide integrated behavioral health services are presented. Investigators used the Behavioral Health Integration in Medical Care (BHIMC) index to measure integration at baseline and follow-up at four FQHCs in New Jersey. Results indicate that the average baseline capability score of 1.95 increased to 2.44 at follow-up, almost one-half point on the five-point BHIMC index. This pilot project demonstrates that co-occurring capability can be assessed, and system-wide technical assistance can be delivered to assist FQHCs in integrating behavioral health services. Future research should test technical assistance as an implementation strategy to promote the integration of medical care and behavioral health treatment on a wider scale.

Background Improving the extent to which evidence-based practices (EBPs)—treatments that have been empirically shown to be efficacious or effective—are integrated within routine practice is a well-documented challenge across numerous areas of health. In 2014, the National Institute on Drug Abuse funded a type 2 effectiveness–implementation hybrid trial titled the substance abuse treatment to HIV Care (SAT2HIV) Project. Aim 1 of the SAT2HIV Project tests the effectiveness of a motivational interviewing-based brief intervention (MIBI) for substance use as an adjunct to usual care within AIDS service organizations (ASOs) as part of its MIBI Experiment. Aim 2 of the SAT2HIV Project tests the effectiveness of implementation and sustainment facilitation (ISF) as an adjunct to the Addiction Technology Transfer Center (ATTC) model for training staff in motivational interviewing as part of its ISF Experiment. The current paper describes the study protocol for the ISF Experiment. Methods Using a cluster randomized design, case management and leadership staff from 39 ASOs across the United States were randomized to receive either the ATTC strategy (control condition) or the ATTC + ISF strategy (experimental condition). The ATTC strategy is staff-focused and includes 10 discrete strategies (e.g., provide centralized technical assistance, conduct educational meetings, provide ongoing consultation). The ISF strategy is organization-focused and includes seven discrete strategies (e.g., use an implementation advisor, organize implementation team meetings, conduct cyclical small tests of change). Building upon the exploration–preparation–implementation–sustainment (EPIS) framework, the effectiveness of the ISF strategy is examined via three staff-level measures: (1) time-to-proficiency (i.e., preparation phase outcome), (2) implementation effectiveness (i.e., implementation phase outcome), and (3) level of sustainment (i.e., sustainment phase outcome). Discussion Although not without limitations, the ISF experiment has several strengths: a highly rigorous design (randomized, hypothesis-driven), high-need setting (ASOs), large sample size (39 ASOs), large geographic representation (23 states and the District of Columbia), and testing along multiple phases of the EPIS continuum (preparation, implementation, and sustainment). Thus, study findings will significantly improve generalizable knowledge regarding the best preparation, implementation, and sustainment strategies for advancing EBPs along the EPIS continuum. Moreover, increasing ASO’s capacity to address substance use may improve the HIV Care Continuum. Trial registration ClinicalTrials.gov: NCT03120598.

This study examined the relationships between substance abuse, mental health problems and HIV risk behavior in offenders discharged from prison and referred to substance abuse treatment programs. Data from 34 sites (n = 1,358) in a federally-funded cooperative agreement, the Criminal Justice Drug Abuse Treatment Studies (CJDATS), were analyzed. Among parolees referred to substance abuse treatment, self reports for the six-month period before the arrest resulting in their incarceration revealed frequent problems with both substance use and mental health. HIV risk behavior was operationalized as either (a) unsafe injection drug use, e.g., sharing needles and/or sharing injection equipment, or (b) unsafe sex, e.g., sex without a condom. The findings were that (1) unsafe injection drug use was associated with unsafe sex and vice versa, (2) unsafe sex behavior was related to frequency of drug use, and (3) unsafe sex behavior was related to frequency of alcohol use. In these samples, mental health problems did not have a significant effect on risk behavior, controlling for other variables. Future research should probe this "nonfinding" using standardized diagnostic and symptom measures to provide greater detail on the mental health problems (e.g., age of onset, frequency, and severity of the problem).

Two nonspecific organizational factors-consensus, defined as agreement within staff and client groups, and concordance, defined as agreement between staff and client groups-were shown to influence client engagement in treatment in a national sample of 80 residential substance abuse treatment programs including 595 staff and 3,732 clients. Agreement was tested using a combined therapeutic community, cognitive-behavioral therapy, and 12-step treatment scale completed by staff and clients. Treatment engagement was measured by the combined scores on the three scales completed by the clients, including engagement, rapport with the counseling process, and confidence in treatment. Within-group consensus was measured by the standard deviations of the mean scores, whereas between-groups concordance was measured by the standard error of the difference between staff and client mean scores. Regression analyses showed that staff consensus was a significant independent predictor of client treatment engagement (p.05), whereas client consensus approached significance (p.10). Concordance was also a significant predictor of client engagement (p.002) after controlling for staff and client consensus. The potential contribution of the findings to a better understanding of program quality and effectiveness of programmatic interventions is discussed.

This study assessed gains that New York State mental health and addiction outpatient clinics achieved in their capacity to provide integrated mental health and substance abuse services for persons with co-occurring disorders. The investigators used two Dual Diagnosis Capability (DDC) indices—one for Addiction Treatment (DDCAT) and one for Mental Health Treatment (DDCMHT)—to measure integration capability at baseline (n = 603) and at follow-up (n = 150), an average of 2 years post-baseline, during which time programs received technical assistance and implementation support. At baseline, the average program score was 2.68, below the “Capable” level (3.0 on a 5-point scale). At follow-up, the average score was 3.04, and the percent of programs rated Capable more than doubled (from 22 to 52%). Programs with lower baseline scores and those with more time to follow-up (2–3 years) had the greatest increases, but 12 to 18 months were sufficient to realize sizeable and significant improvements.

The paper reports on the capability of New York State (NYS) outpatient programs to provide integrated services for co-occurring disorders (COD). Assessments of 447 outpatient clinics, using two dual diagnosis capability indices (one used in addiction settings, the other in mental health settings), produced an overall score of 2.70, interpreted to position NYS clinics closer to "capable" (3.0 = Dual Diagnosis Capable) than to "basic" (1.0 = Alcohol [Mental Health] Only Services). "Assessment" and "Staffing" received the highest scores; i.e., clients with COD were usually identified, and staff (with some additional training and supervision) could treat both disorders effectively. While programs were generally prepared for clients with COD (e.g., welcoming such clients into the program, employing staff with competencies in both disorders, and having established routine screening and assessment to identify COD), results showed that the actual delivery of effective treatment was less satisfactory. The project demonstrated that COD capability can be assessed system-wide, using direct observation.

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.

Previous studies demonstrated the relationship between consensus among both staff and clients with client engagement in treatment and between client consensus and 1-year treatment outcomes. The present article explores the correlates of staff consensus, defined as the level of agreement among staff as to the importance of treatment activities in their program, using a national sample of 80 residential substance abuse treatment programs. Constructive conflict resolution had the largest effect on consensus. Low client-to-staff ratios, staff education, and staff experience in substance abuse treatment were also significantly related to consensus. Frequency of training, an expected correlate of consensus, was negatively associated with consensus, whereas frequency of supervision was not a significant correlate. The implications of the findings for future research and program improvement are discussed.