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

1. Medication-Assisted Treatment Implementation in Community Correctional Environments (MATICCE) CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA.

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

3. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 3 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.

4. 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

5. 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

6. 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

7. 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

8. Sample PEC Membership

9. 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

10. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 10 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

11. Study Design PHASE 1 Pre-Intervention Pilot Phase Test chart data collection procedures May-Jul 2010 (3 mo) Baseline Data Collection (all sites) Aug –Dec 2010 (4 mo) PHASE 2 Knowledge, Attitude, Information (KAI) Intervention (all sites) Jan –Feb ‘11 (2 mo) RANDOMIZATION Group 1 Linkage Intervention PEC Strategic Planning Connection Coordinator Group 2 No Linkage Intervention (KAI only ) PHASE 3 Feb ‘11-Dec ‘12 (12 mo) Jan-’Feb12 (2 mo) End-of-Phase 3 Data Collection (all sites) Jun-Jul 2013 (2 mo) 6-Month Follow-up Data Collection (all sites) Analysis Phase If linkage intervention is effective, offer materials and training to Group 2 After Jul 2012

12. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 12 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

13. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 13 Hypothesis 2 • After the KAI training, CC officers will have  knowledge/attitudes re: evidence for MAT, use in treatment, and where to refer clients • Relates 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

14. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 14 Hypothesis 3 • Staff in KAI + Linkage group will have greater  in intent to refer clients to MAT vs KAI alone • Relates 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

15. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 15 Hypothesis 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

16. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 16 Hypothesis 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

17. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 17 Hypothesis 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 group • Relates 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*

18. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 18 Hypothesis 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.

19. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 19 Challenges 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

20. CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 20 Summary • MAT access could be increased for CC clients by addressing staff knowledge/attitudes and interorganizational linkages • MATICCE -- multi-site, cluster randomized study over 28 months • Compares 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).