cj-dats is funded by nida in collaboration with samhsa and bja. cj-dats is funded by nida in...

CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA.CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA.

Medication-Assisted Treatment Implementation in Community

Correctional Environments (MATICCE)

Why Focus on Interorganizational Linkages to MAT?

Medication Assisted Therapy (MAT) refers adding meds to counseling to ↓ withdrawal, craving & reinforcing euphoria.

MAT Planning Survey RCs surveyed all potential CJ partner sites (N=50) Parole/Probation sites

• lowest current use of MAT• most potential for initiating/expanding MAT

Barriers could be addressed in an implementation design• CC defers responsibility to comm.providers but weak referral relationshps• Lack of knowledge about effectiveness• Philosophical opposition to MAT

MAT access could be increased for Community Corrections (CC) clients by addressing staff knowledge/attitudes and interorganizational linkages

CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA.CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 2

Specific Aims Aim 1: Improve service coordination between CC

agencies and local MAT-providing tx agencies. Aim 2: Improve CC agents’ knowledge, attitudes,

information about referral resources and intent to refer appropriate clients to community-based MAT.

Aim 3: Increase the number of CC clients linked with MAT.

Aims will be accomplished by testing: a staff-level Knowledge, Attitude, and Information (KAI) training

intervention; and an interorganizational linkage intervention.


Two-Part Implementation Strategy: Part 1

Knowledge, attitudes & information (KAI) intervention

Training of CC staff and selected staff from assessment & treatment agencies to address:

• lack of knowledge about effectiveness• philosophical preference for abstinence-based

treatment• Information and understanding about local MAT

resources

Delivered by regional Addiction Technology Transfer Centers (ATTCs) based on NIDA/CSAT Blending Initiative materials

bhall

changed second check mark to specifically name the Blending Initiative

KAI Outline Address CC perspectives on MAT through open

discussion Basics of brain functioning in relation to MAT with

features of special interest to those in criminal justice professions

Medications used to treat alcoholism, evidence about effectiveness and side effects

Medications used to treat opiates, evidence about effectiveness and side effects Examples of typical CC clients who could benefit from MAT

Reasons that those under CC supervision with addiction histories might be good candidates for MAT Rapid re-addiction after release, opiate overdose, alcohol

and violent crime

KAI Outline, cont’d

Advantages that MAT might offer the criminal justice system

evidence-based practice reduced numbers of addicts going through repeated

arrest-incarceration-release cycles would likely result in decreased in crime associated with addiction and in lower public safety costs

formal linkages with medication-assisted treatment agencies could simplify supervision and lower parole/probation supervision costs

How to decide if someone is a good candidate for referral to MAT

Types of agencies where MAT is typically offered

Two-Part Implementation Strategy: Part 2

Interorganizational linkage intervention modeled after CMHS ACCESS

Incorporates 3 parts of ACCESS intervention considered most effective

Pharmacotherapy Exchange Councils (PEC)• Representatives from relevant local agencies • Co-chaired by directors of CC and local MAT

providers (or designees)• Charged to address linkage to MAT-enabled

providers

Sample PEC MembershipSample PEC MembershipPerson RoleCC Director or designee Decision-making authority over policies

Middle manager Supervises CC officers, monitors outcomes

CC Line staff #1 Conducts assessments/discharge plans CC Line staff #2 CC officer Connections Coordinator Provides operational support , liaison OTP Director or designee Decision-making authority over OTP policies Nurse or counselor Does intakes, monitors compliance/ progress

Alcohol treatment Director/designee Decision authority over program policies

Physician/Clinical Director Prescribes & monitors med & outcomes

Clinical supervisor Supervises counselors treating clientsSA single state agency rep. Can influence funding policies and priorities

Other Site-specific: eg. TASC, jail discharge planner, etc.

Two-Part Implementation Strategy: Part II

Interorganizational linkage intervention (cont’d)Strategic Planning by PEC

• Facilitated by local RC investigators• Not top-down “command and control” process• Acknowledge complexity of system

– Minimum specifications, direction-pointing, attractors

“Connections Coordinator” Position• Likely within CC agency• 5 hrs per wk during 11 month linkage intervention period• Compensate agency with $5000 educational travel fund• Coordinate PEC activities; liaison, foster compromise,

consensus among agencies.• Operationalize PEC strategic plan

Sites Intervention based in community corrections (i.e.,

probation/parole) Each CC office would identify at least one local addiction

pharmacotherapy-providing treatment agency to which client referrals can be made

opioid treatment programs providing methadone or buprenorphine outpatient programs providing bup or naltrexone for opioid dep. or

naltrexone, acamprosate or disulfiram for alcohol dependence

Each RC would contribute at least 2 CJ sites to the protocol, preferably in distinct geographic catchment areas

Catchment area distinction helps avoid contamination (especially of tx providers) in the delayed implementation group


Study Design

Baseline Data Collection (all sites)

Knowledge, Attitude, Information (KAI) Intervention (all sites)

RANDOMIZATION

May-Jul 2010(3 mo)

Jan –Feb ‘11(2 mo)

Group 1Linkage Intervention

PECStrategic Planning

Connection Coordinator

PHASE 1

Group 2No Linkage

Intervention (KAI only )

End-of-Phase 3 Data Collection (all sites)

6-Month Follow-up Data Collection (all sites)

PHASE 2

PHASE 3

Feb ‘11-Dec ‘12(12 mo)

Jan-’Feb12(2 mo)

Aug –Dec 2010 (4 mo)

Jun-Jul 2013(2 mo)

Pre-Intervention Pilot PhaseTest chart data collection procedures

If linkage intervention is effective, offer materials and training to Group 2

After Jul 2012Analysis

Phase

Hypothesis 1 CC units in the KAI+Linkage intervention will have

greater relative to baseline in interorganizational tx svc coordination than those with KAI alone.Relates to Aim 1 (improve service coordination)

• Compares Groups 1 (KAI+Linkage) & 2 (KAI) at end of Phase 3

Outcomes• Services Coordination Scale (Fletcher., 2009)

• ACCESS measures (e.g., Morrissey et al., 2002) • Organizational Assessment Instrument (Van de Ven, 1980)

Data sources• Semi-structured interviews & CC staff surveys at baseline & end

of Phase 3


Hypothesis 2Hypothesis 2

After the KAI training, CC officers will have knowledge/attitudes re: evidence for MAT, use in treatment, and where to refer clientsRelates to Aim 2 (staff knowledge & intent)

• Compares staff baseline-post KAI training in both groups

Outcomes• CTN items (Fitzgerald & McCarty, 2009); Attitudes toward

Medications19-item scale (Springer & Bruce, 2008); Gjersing et al. 2007; able to name two local MAT providers

Data sources• CC staff surveys at baseline and after KAI training


Hypothesis 3Hypothesis 3 Staff in KAI + Linkage group will have greater in

intent to refer clients to MAT vs KAI aloneRelates to Aim 2 (staff knowledge & intent to refer)

• Compares Group 1 vs. Group 2 staff baseline-post Phase 3.

Outcomes• Intent to refer on Likert-type scales (Varra et al., 2008)

Data sources• CC staff surveys at baseline & end of Phase 3


Hypothesis 4Hypothesis 4 ’d interorganizational tx service coordination and

staff knowledge / attitudes / referral practices will be sustained 6 months after intervention period.Relates to Aim 1 (service coordination)

• Compares Group 1 vs. Group 2 across all data collection periods

Outcomes• Interorganizational coordination measures per H1• KAI and intent to refer scales per H2, H3

Data sources• CC staff surveys, semi-structured interviews at baseline, end of

Phase 3 & 6-months later


Hypothesis 5Hypothesis 5 CC units in KAI+Linkage group will have a greater

over baseline in % opioid/alcohol-using clients referred to MAT assessment than KAI only group.Relates to Aim 3 (increase client linkages)

• Compares Group 1 vs. Group 2 across all data collection periods

Outcomes• % opioid-/alcohol- using clients referred for assessment for MAT

Data sources (see: Agency Records Slide)• CC records for 6 mos prior to baseline, last 6 months of Phase 3,

and 6 months after Phase 3*• Monthly CC officer survey for month prior to baseline, last 6

months of Phase 3, and 6 months after Phase 3, reporting:– # opioid/alcohol-using clients – # clients referred for MAT assessment


Hypothesis 6Hypothesis 6 CC units in KAI + Linkage group will have a greater

over baseline in clients assessed by a tx provider for MAT and who initiate MAT, vs. KAI only groupRelates to Aim 3 (increase client linkages)

• Compares Group 1 vs. Group 2 staff baseline-Phase 3

Outcomes• # completed CJ referrals for assessment, MAT initiates, person-days on

MAT

Data sources (see: Agency Records Slide)• Records abstract or report from substance abuse assessment provider

and main MAT program for 6 mos prior to baseline & last 6 mos of Phase 3*


Hypothesis 7Hypothesis 7 CC units in KAI+Linkage group will have a larger

relative to baseline in opioid/alcohol-using clients rearrested, re-incarcerated, & testing positive for substance use relative to KAI only group.Relates to Aim 3 (increase client linkages)

• Compares Group 1 vs. Group 2 staff baseline-Phase 3.

Outcomes: Of “potentially MAT appropriate” CC clients i• % arrested, reincarcerated, testing positive for drugs

Data sources (see: Agency Records Slide)• Records abstract or report from CC, CJ and drug-testing program

for 6 mos prior to baseline, last 6 mos of Phase 3, & 6 mos after Phase 3.


Challenges and LimitationsChallenges and Limitations Site cannot accept randomization assignment

MATICCE EC will recommend action, incl replacement if necessary. Protocol deviations

Change in staff or level of cooperation• Retraining• Analyses by intent to treat

Client Information – need decision on options Waiver

• IRB variability• Unclear whether treatment programs will honor waiver• Can still examine primary outcomes from CJ and survey data

Extent, validity of record documentation – to be determined from pilot Possible detection bias based on Group (hard to blind RAs)

Self-report data Limited information on psychometrics of such reports Social desirability / Hawthorne effects


SummarySummary MAT access could be increased for CC clients by

addressing staff knowledge/attitudes and interorganizational linkages

MATICCE -- multi-site, cluster randomized study over 28 monthsCompares KAI training alone versus KAI training plus active

linkage intervention• Interorganizational Pharmacotherapy Exchange Council (PEC)• Facilitated strategic planning• Connections coordinator position

Addresses implementation science (interorg. relationships; sustainability); HSR (structural influences on access, referral, and utilization) & practical concerns of CJ agencies (facilitating interagency referrals; reducing relapse & arrest).


cj-dats is funded by nida in collaboration with samhsa and bja. cj-dats is funded by nida in...

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