Supportive Housing for Sexual and Gender Minority Individuals with Criminal Justice Histories: Challenges and Opportunities Identified by Providers and Clients.

Sexual and gender minority (SGM) individuals experience high rates of homelessness and criminal justice system involvement, underscoring the need for supportive housing services. To explore the service needs of this population, we interviewed providers (n = 11) and clients (n = 10) from eight supportive housing organizations working with SGM populations in Los Angeles County, USA. We used the Consolidated Framework for Implementation Research to synthesize interview responses into themes (by domain and cross-cutting). Take-aways included the need for investment in systems of care for vulnerable SGM populations; the particular marginalization of Trans individuals and providers that serve them; the roles of supportive housing staff, residents, and leadership in cultivating an affirming environment; prevalence of discrimination and stigma within supportive housing programs and broader society; and the complex interrelationships among SGM identity, homelessness, and criminal justice system involvement. These findings have important implications for supportive housing services and related policy.

Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness.

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

Organizational Capacity and Readiness to Provide Medication for Individuals with Co-Occurring Alcohol Use Disorders in Public Mental Health Settings.

Alcohol use disorders (AUD) in individuals with mental illness are largely untreated. The purpose of this study was to identify gaps in organizational capacity and readiness to provide medications for AUD in outpatient public mental health clinics. We selected a purposive sample of eight publicly funded outpatient mental health clinics operated by the Los Angeles County Department of Mental Health; clinics were chosen to maximize heterogeneity. Guided by theories of organizational capacity and readiness and research on the adoption of pharmacotherapy for AUD in primary and specialty care treatment settings, we conducted semi-structured interviews and focus groups with administrators, providers and staff, and a qualitative analysis of the results. Respondents described significant organizational capacity and behavioral readiness constraints to providing medication treatment for AUD. Both groups articulated a perception that mental health clinics were not designed to provide co-occurring AUD treatment because of large caseloads, staffing configurations, and time constraints that did not support the delivery of appropriate treatment, and a lack of protocols and workflow procedures. We documented organizational capacity and readiness constraints which impede the delivery of medication treatment for AUD in a large mental helth system. While some constraints have straightforward solutions, others require structural changes to the way care is delivered, and state-level funding and policy changes.

Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study.

BACKGROUND: Millions of people with substance use disorders (SUDs) need, but do not receive, treatment. Delivering SUD treatment in primary care settings could increase access to treatment because most people visit their primary care doctors at least once a year, but evidence-based SUD treatments are underutilized in primary care settings. We used an organizational readiness intervention comprised of a cluster of implementation strategies to prepare a federally qualified health center to deliver SUD screening and evidence-based treatments (extended-release injectable naltrexone (XR-NTX) for alcohol use disorders, buprenorphine/naloxone (BUP/NX) for opioid use disorders and a brief motivational interviewing/cognitive behavioral -based psychotherapy for both disorders). This article reports the effects of the intervention on key implementation outcomes. METHODS: To assess changes in organizational readiness we conducted pre- and post-intervention surveys with prescribing medical providers, behavioral health providers and general clinic staff (N = 69). We report on changes in implementation outcomes: acceptability, perceptions of appropriateness and feasibility, and intention to adopt the evidence-based treatments. We used Wilcoxon signed rank tests to analyze pre- to post-intervention changes. RESULTS: After 18 months, prescribing medical providers agreed more that XR-NTX was easier to use for patients with alcohol use disorders than before the intervention, but their opinions about the effectiveness and ease of use of BUP/NX for patients with opioid use disorders did not improve. Prescribing medical providers also felt more strongly after the intervention that XR-NTX for alcohol use disorders was compatible with current practices. Opinions of general clinic staff about the appropriateness of SUD treatment in primary care improved significantly. CONCLUSIONS: Consistent with implementation theory, we found that an organizational readiness implementation intervention enhanced perceptions in some domains of practice acceptability and appropriateness. Further research will assess whether these factors, which focus on individual staff readiness, change over time and ultimately predict adoption of SUD treatments in primary care.

Bayesian restricted spatial regression for examining session features and patient outcomes in open-enrollment group therapy studies.

Group-based interventions have been developed for treating patients across a range of health conditions. Enrollment into such groups often occurs on an open (or rolling) basis. Conditional autoregression modeling of random session effects has been proposed to account for the expected correlation in session effects associated with the overlap in patient participation session to session. However, when the analytic objective is to examine the relationship between a fixed-effect session feature and a patient outcome using conditional autoregression, confounding might arise if the fixed session feature of interest and the random session effects vary across sessions in similar ways, resulting in bias and inflated standard errors of a fixed-effect session feature of interest. Motivated by the goal of examining the relationships between outcomes and the session features of leader and session module theme, we applied restricted spatial regression to the analysis of patient outcomes collected from 132 participants in an open-enrollment group for treating depression among patients of a residential alcohol and other drug treatment program, adapting the approach to the multilevel data structure of open-enrollment group data. As compared with standard conditional autoregression, the restricted regression approach resulted in more precise estimates of regression coefficients of the module theme and leader predictor variables. The restricted regression approach provides an important analytic tool for group therapy researchers who are investigating the relationship between key components of open-enrollment group therapy interventions and patient outcomes.

The effects of mental health symptoms and marijuana expectancies on marijuana use and consequences among at-risk adolescents.

Based on expectancy theory, adolescents at risk for mental health symptoms, such as those involved in the juvenile court system, may use marijuana due to the belief that use will attenuate anxiety and depressive symptoms. In a diverse sample of youth involved in the Santa Barbara Teen Court system (N = 193), we examined the association between mental health symptoms and marijuana expectancies on marijuana use and consequences. In general, stronger positive expectancies and weaker negative expectancies were both associated with increased marijuana use. Youth that reported more symptoms of both anxiety and depression and stronger positive expectancies for marijuana also reported more consequences. We found that youth experiencing the greatest level of consequences from marijuana were those that reported more depressive symptoms and stronger positive expectancies for marijuana. Findings suggest that these symptoms, combined with strong positive expectancies about marijuana's effects, have implications for consequences among at-risk youth.

Multi-level alignment processes in the sustainment of a youth substance use treatment model following a federal implementation initiative: A mixed method study.

INTRODUCTION: Government agencies have identified evidence-based practice (EBP) dissemination as a pathway to high-quality behavioral health care for youth. However, gaps remain about how to best sustain EBPs in treatment organizations in the U.S., especially in resource-constrained settings like publicly-funded youth substance use services. One important, but understudied, determinant of EBP sustainment is alignment: the extent to which multi-level factors that influence sustainment processes and outcomes are congruent, consistent, and/or coordinated. This study examined the role of alignment in U.S. states' efforts to sustain the Adolescent Community Reinforcement Approach (A-CRA), an EBP for youth substance use disorders, during the COVID-19 pandemic. METHODS: In this mixed methods study, the qualitative investigation preceded and informed the quantitative investigation. We interviewed state administrators and providers (i.e., supervisors and clinicians) from 15 states that had completed a federal A-CRA implementation grant; providers also completed surveys. The sample included 50 providers from 35 treatment organizations that reported sustaining A-CRA when the COVID-19 pandemic began, and 20 state administrators. In qualitative thematic analyses, we applied the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to characterize alignment processes that interviewees described as influential on sustainment. We then used survey items to quantitatively explore the associations described in qualitative themes, using bivariate linear regressions. RESULTS: At the time of interview, staff from 80 % of the treatment organizations (n = 28), reported sustaining A-CRA. Providers from both sustainer and non-sustainer organizations, as well as state administrators, described major sources of misalignment when state agencies ceased technical assistance post-grant, and because limited staff capacity conflicted with A-CRA's training model, which was perceived as time-intensive. Participants described the pandemic as exacerbating preexisting challenges, including capacity issues. Sustainer organizations reported seeking new funding to help sustain A-CRA. Quantitative associations between self-rated extent of sustainment and other survey items largely followed the pattern predicted from the qualitative findings. CONCLUSIONS: The COVID-19 pandemic amplified longstanding A-CRA sustainment challenges, but treatment organizations already successfully sustaining A-CRA pre-pandemic largely continued. There are missed opportunities for state-level actors to coordinate with providers on the shared goal of EBP sustainment. A greater focus on alignment processes in research and practice could help states and providers strengthen sustainability planning.

Availability of Medications for Opioid Use Disorder in Community Mental Health Facilities.

Importance: Medications for opioid use disorder (MOUD) are an effective but underutilized treatment. Opioid use disorder prevalence is high among people receiving treatment in community outpatient mental health treatment facilities (MHTFs), but MHTFs are understudied as an MOUD access point. Objective: To quantify availability of MOUD at community outpatient MHTFs in high-burden states as well as characteristics associated with offering MOUD. Design, Setting, and Participants: This cross-sectional study performed a phone survey between April and July 2023 among a representative sample of community outpatient MHTFs within 20 states most affected by the opioid crisis, including all Certified Community Behavioral Health Centers (CCBHCs). Participants were staff at 450 surveyed community outpatient MHTFs in 20 states in the US. Main Outcomes and Measures: MOUD availability. A multivariable logistic regression was fit to assess associations of facility, county, and state-level characteristics with offering MOUD. Results: Surveys with staff from 450 community outpatient MHTFs (152 CCBHCs and 298 non-CCBHCs) in 20 states were analyzed. Weighted estimates found that 34% (95% CI, 29%-39%) of MHTFs offered MOUD in these states. Facility-level factors associated with increased odds of offering MOUD were: self-reporting being a CCBHC (odds ratio [OR], 2.11 [95% CI, 1.08-4.11]), providing integrated mental and substance use disorder treatment (OR, 5.21 [95% CI, 2.44-11.14), having a specialized treatment program for clients with co-occurring mental and substance use disorders (OR, 2.25 [95% CI, 1.14-4.43), offering housing services (OR, 2.54 [95% CI, 1.43-4.51]), and laboratory testing (OR, 2.15 [95% CI, 1.12-4.12]). Facilities that accepted state-financed health insurance plans other than Medicaid as a form of payment had increased odds of offering MOUD (OR, 1.95 [95% CI, 1.01-3.76]) and facilities that accepted state mental health agency funds had reduced odds (OR, 0.43 [95% CI, 0.19-0.99]). Conclusions and Relevance: In this study of 450 community outpatient MHTFs in 20 high-burden states, approximately one-third offered MOUD. These results suggest that further study is needed to report MOUD uptake, either through increased prescribing at all clinics or through effective referral models.

Narrative review: Revised Principles and Practice Recommendations for Adolescent Substance Use Treatment and Policy.

OBJECTIVE: In 2014, the U.S. National Institute on Drug Abuse released the "Principles of Adolescent Substance Use Disorder Treatment," summarizing previously established evidence and outlining principles of effective assessment, treatment, and aftercare for substance use disorders (SUD). Winters et al. (2018) updated these principles to be developmentally appropriate for adolescents. This review builds on that formative work and recommends updated adolescent assessment, treatment, and aftercare principles and practices. METHOD: The Cochrane, MEDLINE-PubMed, and PsychInfo databases were searched for relevant studies with new data about adolescent substance use services. This article updates the 13 original principles; condenses the 8 original modalities into 5 practices; and highlights implications for public policy approaches, future funding, and research. RESULTS: Key recommendations from the principles include integrating care for co-occurring mental health disorders and SUDs, improving service accessibility including through the educational system, maintaining engagement, and addressing tension between agencies when collaborating with other youth service systems. Updates to the treatment practices include adoption of Screening, Brief Intervention and Referral to Treatment (SBIRT), investment in social programs and family involvement in treatment, expanding access to behavioral therapies and medications, increasing funding to harm reduction services, supporting reimbursement for continuing care services, and increasing investment in research. CONCLUSION: These revised principles of adolescent assessment, treatment, and aftercare approaches and practices aim to establish guidance and evidence-based practices for treatment providers, while encouraging necessary support from policymakers and funding agencies to improve the standard of care for adolescent SUD services.

Training Addiction Counselors to Implement an Evidence-Based Intervention: Strategies for Increasing Organizational and Provider Acceptance.

One barrier to widespread public access to empirically supported treatments (ESTs) is the limited availability and high cost of professionals trained to deliver them. Our earlier work from two clinical trials demonstrated that front-line addiction counselors could be trained to deliver a manualized, group-based cognitive behavioral therapy (GCBT) for depression, a prototypic example of an EST, with a high level of adherence and competence. This follow-up article provides specific recommendations for the selection and initial training of counselors, and for the structure and process of their ongoing clinical supervision. Unique challenges in working with counselors unaccustomed to traditional clinical supervision are highlighted. The recommendations are based on comprehensive feedback derived from clinician notes taken throughout the clinical trials, a focus group with counselors conducted one year following implementation, and interviews with key organization executives and administrators.

Just in Reach Pay for Success: Impact Evaluation and Cost Analysis of a Permanent Supportive Housing Program.

Discharging individuals from jails and prisons who may be poorly equipped for independent living-such as those with a history of chronic health conditions, including serious mental illness-is likely to reinforce a pattern of homelessness and recidivism. Permanent supportive housing (PSH)-which combines a long-term housing subsidy with supportive services-has been proposed as a mechanism to intervene directly on this relationship between housing and health. In Los Angeles County, jail has become a default housing and services provider to unhoused individuals with serious mental health issues. In 2017, the county initiated the Just in Reach Pay for Success (JIR PFS) project, which provided PSH as an alternative to jail for individuals with a history of homelessness and chronic behavioral or physical health conditions. The authors of this study assessed whether the project led to changes in use of several county services, including justice, health, and homeless services. The authors examined changes in county service use, before and after incarceration, by JIR PFS participants and a comparison control group and found that use of jail services was significantly reduced after JIR PFS PSH placement, while the use of mental health and other services increased. The researchers assess that the net cost of the program is highly uncertain but that it may pay for itself in terms of reducing the use of other county services and therefore provide a cost-neutral means of addressing homelessness among individuals with chronic health conditions involved with the justice system in Los Angeles County.

Comparing organization-focused and state-focused financing strategies on provider-level reach of a youth substance use treatment model: a mixed-method study.

BACKGROUND: Financial barriers in substance use disorder service systems have limited the widespread adoption-i.e., provider-level reach-of evidence-based practices (EBPs) for youth substance use disorders. Reach is essential to maximizing the population-level impact of EBPs. One promising, but rarely studied, type of implementation strategy for overcoming barriers to EBP reach is financing strategies, which direct financial resources in various ways to support implementation. We evaluated financing strategies for the Adolescent Community Reinforcement Approach (A-CRA) EBP by comparing two US federal grant mechanisms, organization-focused and state-focused grants, on organization-level A-CRA reach outcomes. METHOD: A-CRA implementation took place through organization-focused and state-focused grantee cohorts from 2006 to 2021. We used a quasi-experimental, mixed-method design to compare reach between treatment organizations funded by organization-focused versus state-focused grants (164 organizations, 35 states). Using administrative training records, we calculated reach as the per-organization proportion of trained individuals who received certification in A-CRA clinical delivery and/or supervision by the end of grant funding. We tested differences in certification rate by grant type using multivariable linear regression models that controlled for key covariates (e.g., time), and tested threats to internal validity from our quasi-experimental design through a series of sensitivity analyses. We also drew on interviews and surveys collected from the treatment organizations and (when relevant) interviews with state administrators to identify factors that influenced reach. RESULTS: The overall certification rates were 27 percentage points lower in state-focused versus organization-focused grants (p = .01). Sensitivity analyses suggested these findings were not explained by confounding temporal trends nor by organizational or state characteristics. We did not identify significant quantitative moderators of reach outcomes, but qualitative findings suggested certain facilitating factors were more influential for organization-focused grants (e.g., strategic planning) and certain barrier factors were more impactful for state-focused grants (e.g., states finding it difficult to execute grant activities). DISCUSSION: As the first published comparison of EBP reach outcomes between financing strategies, our findings can help guide state and federal policy related to financing strategies for implementing EBPs that reduce youth substance use. Future work should explore contextual conditions under which different financing strategies can support the widespread implementation of EBPs for substance use disorder treatment.

Employing continuous quality improvement in community-based substance abuse programs.

PURPOSE: This article aims to describe continuous quality improvement (CQI) for substance abuse prevention and treatment programs in a community-based organization setting. DESIGN/METHODOLOGY/APPROACH: CQI (e.g., plan-do-study-act cycles (PDSA)) applied in healthcare and industry was adapted for substance abuse prevention and treatment programs in a community setting. The authors assessed the resources needed, acceptability and CQI feasibility for ten programs by evaluating CQI training workshops with program staff and a series of three qualitative interviews over a nine-month implementation period with program participants. The CQI activities, PDSA cycle progress, effort, enthusiasm, benefits and challenges were examined. FINDINGS: Results indicated that CQI was feasible and acceptable for community-based substance abuse prevention and treatment programs; however, some notable resource challenges remain. Future studies should examine CQI impact on service quality and intended program outcomes. RESEARCH LIMITATIONS/IMPLICATIONS: The study was conducted on a small number of programs. It did not assess CQI impact on service quality and intended program outcomes. Practical implications- This project shows that it is feasible to adapt CQI techniques and processes for community-based programs substance abuse prevention and treatment programs. These techniques may help community-based program managers to improve service quality and achieve program outcomes. ORIGINALITY/VALUE: This is one of the first studies to adapt traditional CQI techniques for community-based settings delivering substance abuse prevention and treatment programs.

Implementation and 12-Month Health Service Utilization and Cost Outcomes from a Managed Care Health Plan's Permanent Supportive Housing Program.

Homelessness, which refers to the lack of a fixed, regular, and adequate nighttime residence, is a pervasive public health issue. This article presents results from an implementation and outcome study of an ongoing permanent supportive housing (PSH) program-including service utilization and associated costs review-operated by a large not-for-profit Medicaid and Medicare managed care plan serving more than 1 million members in the Inland Empire area of Southern California. This PSH program combines a long-term housing subsidy with intensive case management services for adult plan members experiencing homelessness who have one or more chronic physical or behavioral health conditions and represent high utilizers of inpatient health care. The aim of this research was to determine whether programmatic costs incurred by the health plan supporting the PSH program were partially or fully offset by decreased costs attributable to health care utilization within the health system. The evaluation used a quasi-experimental research design with an observational control group. The authors differentiated the program's effect during the transitional period-that is, after program enrollment and prior to housing placement-from its effect during the period after members were housed. In addition, the authors present participant flow through the key program milestones (e.g., referral, enrollment, housing placement, program exit) and describe health care utilization and associated costs for members who exited the program. Finally, they report the PSH programmatic expenditures relative to the changes in health care costs to provide an overall picture of the intervention's benefits and costs to the health plan.

Restructuring personal networks with a Motivational Interviewing social network intervention to assist the transition out of homelessness: A randomized control pilot study.

BACKGROUND: Social relationships play a key role in both substance use and homelessness. Transitioning out of homelessness often requires reduction in substance use as well as changes in social networks. A social network-based behavior change intervention that targets changes personal social networks may assist the transition out of homelessness. Most behavior change interventions that incorporate social networks assume a static network. However, people experiencing homelessness who transition into housing programs that use a harm reduction approach experience many changes in their social networks during this transition. Changes may include disconnecting from street-based network contacts, re-connecting with former network contacts, and exposure to new network members who actively engage in substance use. An intervention that helps people transitioning out of homelessness make positive alterations to their social networks may compliment traditional harm reduction housing program services. METHODS: We conducted a pilot randomized controlled trial (RCT) of an innovative Social Network Intervention (MI-SNI), which combines network visualization and Motivational Interviewing to assist adults transitioning out of homelessness. The MI-SNI provides feedback to new residents about their social environments and is designed to motivate residents to make positive changes in both their individual behavior and their personal network. In a sample of 41 adult housing program residents with past year risky substance use, we examined whether participants randomized to receive a MI-SNI showed greater changes in their personal networks over 3 months compared to those receiving usual care. RESULTS: There were significant differences in the networks of the MI-SNI group compared to the group receiving usual care at follow-up, controlling for baseline network characteristics. The MI-SNI group had greater reductions in the proportion of their network members who influenced alcohol or other drug use (AOD) use, such as drinking partners, and more frequently changed their relationships in the direction of lower AOD risk with network members who were retained in their networks across waves. CONCLUSIONS: This study is the first pilot test of a MI-SNI customized for assisting the transition out of homelessness to test for personal network changes. Results indicate that MI-SNIs can have a positive impact on short-term network changes and thus may serve as a useful adjunct to behavioral change interventions. These findings suggest that a MI-SNI approach may help individuals experiencing homelessness and risky AOD use positively restructure their social networks while transitioning into supportive housing. These promising results suggest the need for a larger RCT test of this innovative intervention approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02140359.

Comparing two federal financing strategies on penetration and sustainment of the adolescent community reinforcement approach for substance use disorders: protocol for a mixed-method study.

BACKGROUND: Sustained, widespread availability of evidence-based practices (EBPs) is essential to address the public health and societal impacts of adolescent substance use disorders (SUD). There remains a particularly significant need to identify effective financing strategies, which secure and direct financial resources to support the costs associated with EBP implementation and sustainment. This protocol describes a new project comparing two types of U.S. federal grant mechanisms (i.e., a type of financing strategy), which supported the implementation of the Adolescent Community Reinforcement Approach (A-CRA) EBP for SUD, through either organization-focused or state-focused granting of funds. The Exploration-Preparation-Implementation-Sustainment (EPIS) framework will guide our study aims, hypotheses, and selection of measures. METHOD: We will employ a longitudinal, mixed-method (i.e., web surveys, semi-structured interviews, document review, focus groups, administrative data), quasi-experimental design to compare the grant types' outcomes and examine theoretically informed mediators and moderators. Aim 1 will examine the proportion of eligible clinicians certified in A-CRA with adequate fidelity levels (i.e., penetration outcomes) at the end of grant funding. Aim 2 will examine the sustainment of A-CRA up to 5 years post-funding, using a 10-element composite measure of treatment delivery and supervision activities. We will integrate the new data collected from state-focused grant recipients (~85 organizations in 19 states) with previously collected data from organization-focused grant recipients (Hunter et al., Implement Sci 9:104, 2014) (82 organizations in 26 states) for analysis. We will also use sensitivity analyses to characterize the effects of observed and unobserved secular trends in our quasi-experimental design. Finally, aim 3 will use comparative case study methods (integrating diverse quantitative and qualitative measures) to identify and disseminate policy implications about the roles of state- and organization-focused federal grants in efforts to promote adolescent SUD EBP implementation and sustainment. DISCUSSION: The proposed research will have direct, practical implications for behavioral health administrators, policymakers, implementation experts, and the public. It will offer new knowledge that can directly inform financing strategies to support large-scale, sustained EBP delivery in behavioral health-while advancing implementation science through the use of novel methods to study financing strategies and sustainment.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness.

OBJECTIVE: The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics. METHODS: Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed. RESULTS: In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, ß=13.54, p=0.003, and naltrexone long-acting injection, ß=15.83, p<0.001). CONCLUSIONS: These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

Training addiction counselors to implement CBT for depression.

Many clients in publicly funded substance abuse treatment programs suffer from depression yet lack access to effective mental health treatment. This study sought to examine whether addiction counselors could be effectively trained to deliver group CBT for depression and to ascertain client perceptions of the treatment. Five counselors were trained in the therapy and treated 113 clients with depression symptoms. Counselors demonstrated high fidelity to the therapy and client perceptions of the therapy were positive. Our results suggest that training addiction counselors to deliver group CBT for depression is a promising integrated treatment approach for co-occurring depression and substance disorders.

Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study.

OBJECTIVES: During the COVID-19 pandemic, opioid treatment programs (OTPs) in the U.S. were granted new flexibility in methadone dispensing and the use of telemedicine. To explore the impact of the pandemic and accompanying policy changes on service delivery, we asked OTP clinicians about changes in care patterns and perceptions of impacts on access and quality. METHODS: In May-June 2020, we completed semistructured telephone interviews with 20 OTP clinicians (physicians, physician assistants, and nurse practitioners) from 13 U.S. states. The study recruited participants through Medscape, an online platform where clinicians access clinical content. We used rapid thematic analysis, a qualitative approach, to summarize participants' expressed views related to the research objectives. RESULTS: Clinicians identified a range of changes to methadone and ancillary service delivery as a result of COVID-19. Most clinicians reported that OTPs were prescribing more take-home doses of methadone and providing psychosocial services and medication management via telemedicine. Many also reported reducing the frequency of urine toxicology screening and accepting fewer new patients. While some clinicians expressed support for the increased flexibility around dosing and use of telemedicine, others expressed concern about increased risk of medication diversion and overdose. Clinicians reported several advantages and disadvantages of the changes due to the pandemic and that continued reimbursement would be required to maintain telemedicine services. CONCLUSIONS: The COVID-19 pandemic dramatically altered the delivery of methadone treatment in the U.S. This study's findings suggest that OTPs may have reduced their methadone treatment during the early months of the pandemic and that the flexibilities that policy changes offered may not have resulted in changes in care delivery for all patients. Careful consideration and additional analysis should inform which changes OTPs should maintain long-term.

Perceived care coordination among permanent supportive housing participants: Evidence from a managed care plan in the United States.

Homelessness is a pervasive public health problem in the United States (U.S.). Under the U.S. Affordable Care Act, the nation's public health insurance program (Medicaid) was expanded to serve more individuals, including those experiencing homelessness. Coupled with changes in financial incentives designed to reduce healthcare costs, health plans, hospitals and large health systems have started to operate permanent supportive housing (PSH) programmes as a healthcare benefit. To better understand patient perceptions of care coordination in a PSH programme operated by a large health plan in Southern California, we conducted 22 semi-structured in-depth patient interviews between October and November 2019. Two coders analysed these data inductively and deductively, using pre-identified domains and open coding. Coding reliability and thematic saturation were also assessed. Findings indicated positive experiences with care coordination for physical health and social supports, such as food distribution and transportation. Identified service gaps included mental health support and help securing public assistance (e.g., cash benefits). Opportunities to enhance PSH care coordination were also identified, such as the need for a simplified approach. Hospitals, health plans and systems considering PSH programmes may look to these results for implementation guidance.