The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders.

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.

Virtual training and technical assistance: a shift in behavioral health workforce access and perceptions of services during emergency restrictions.

BACKGROUND: To respond to the COVID-19 pandemic, the Substance Abuse and Mental Health Services Administration-funded Technology Transfer Centers had to rapidly adapt to ensure that the behavioral health workforce had continuous access to remote training and technical assistance (TTA). Although the Technology Transfer Centers have historically relied partially upon virtual methods for delivering TTA, the shift to a strictly virtual approach necessitated by COVID-19 restrictions has raised new questions for how to best proceed with services when social distancing guidelines are relaxed. The objective of this exploratory paper was to compare TTA provision in the six-month period prior to (9/1/19 thru 2/28/20) and during (4/1/20 thru 9/30/20) early COVID-19 restrictions to determine the extent to which the shift to virtual service provision impacted the behavioral health and medical workforce. Specifically, we examined participants' access to TTA, geographic reach of TTA, and workforce perceptions of satisfaction and utility with TTA provision. METHOD: Participant and event-level data were analyzed to compare the following metrics before and during the COVID pandemic: number of events and attendees; participant demographics; zip codes reached; coverage of rural, suburban, and urban areas; and perceptions of satisfaction with and utility of training. RESULTS: Findings showed a 40% increase in the number of events delivered (p < .001) and a 270% increase in the number of attendees (p < .001) during the COVID period when TTCs relied exclusively on virtual delivery. Geospatial analyses linking zip codes to a schematic of rural, suburban, and urban classifications throughout the United States revealed significant increases in the number of zip codes reached during the COVID time period. Satisfaction levels were comparable before and during the pandemic. CONCLUSIONS: Findings show that expanded access to TTA services via virtual formats resulted in reach to more diverse attendees and regions, and did not come at the expense of satisfaction. Results suggest that virtual TTA should continue to be an important component of TTA offerings post-pandemic.

Dual diagnosis capability in mental health and addiction treatment services: an assessment of programs across multiple state systems.

Despite increased awareness of the benefits of integrated services for persons with co-occurring substance use and psychiatric disorders, estimates of the availability of integrated services vary widely. The present study utilized standardized measures of program capacity to address co-occurring disorders, the dual diagnosis capability in addiction treatment and dual diagnosis capability in mental health treatment indexes, and sampled 256 programs across the United States. Approximately 18 % of addiction treatment and 9 % of mental health programs met criteria for dual diagnosis capable services. This is the first report on public access to integrated services using objective measures.

Supporting Implementation Through Online Learning Communities: Lessons Learned From a National Training and Technical Assistance Network.

Recent implementation science frameworks highlight the role of training and technical assistance (TTA) in building workforce capacity to implement evidence-based practices (EBPs). However, evaluation of TTA is limited. We describe three case examples that highlight TTA by three regional centers in the national Mental Health Technology Transfer Center (MHTTC) network. Each MHTTC formed Learning Communities (LCs) to facilitate connections among behavioral health professionals with the goals of sharing implementation strategies, discussing best-practices, and developing problem solving techniques. Data on outcomes were collected through a combination of self-report surveys and qualitative interviews. LC participants reported strong connectedness, gains in knowledge and skills, improvements in implementation capacity, and intentions to advocate for organizational and systems-level change. Furthermore, across the case examples, we identified LC characteristics that are associated with participant perceptions of outcomes, including tailoring LC content to workforce needs, providing culturally relevant information, engaging leaders, forming connections among participants and trainers, and challenging participants' current workplace practices. These findings are interpreted through the lens of the Interactive Systems Framework, which focuses on how TTA, such as LCs, can facilitate connections between the theoretical and empirical foundations of interventions and the practices of implementing interventions in real-world settings to advance workforce capacity.

Confirming the factor structure of the alcohol and alcohol problems questionnaire (AAPPQ) in a sample of baccalaureate nursing students.

The Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) is a multi-dimensional measure of clinicians' attitudes toward working with patients with alcohol problems. In the past 35 years, five- and six-subscale versions and a short version of the AAPPQ have been published. While the reliability of the AAPPQ subscales has remained acceptable, the factor structure has not been verified using confirmatory techniques. In the current study, we split a sample of 299 baccalaureate nursing students to use exploratory (EFA) and confirmatory factor analyses (CFA). When compared to the original six-factor solution and an imposed six-factor structure in CFA, the EFA seven-factor solution with three original items (19, 20, and 25) removed had the best model fit.

Effects of Screening, Brief Intervention, and Referral to Treatment (SBIRT) education and training on nursing students' attitudes toward working with patients who use alcohol and drugs.

BACKGROUND: Screening, Brief Intervention, and Referral to Treatment (SBIRT) can reduce alcohol use and negative health outcomes in patients with risky substance use. However, negative attitudes that some health care professionals have toward patients who use substances are a barrier to implementing SBIRT. METHODS: The University of Pittsburgh School of Nursing, in partnership with the Institute for Research, Education, and Training in Addictions (IRETA), developed a curriculum to train baccalaureate student nurses to deliver SBIRT. RESULTS: Following SBIRT education and training, students' perceived attitudes toward patients who use alcohol became more positive. Less robust changes were found for attitudes related to patients who use drugs. CONCLUSIONS: Nurses composing the largest group of healthcare workers are in key positions to screen, intervene, and provide education about substance use.

Screening, brief intervention, and referral to treatment: overview of and student satisfaction with an undergraduate addiction training program for nurses.

Preparing nursing students to apply an evidence-based screening and brief intervention approach with patients has the potential to reduce patients' risky alcohol and drug use. Responding to Mollica, Hyman, and Mann's article published in 2011, the current article describes implementation results of an Addiction Training for Nurses program of Screening, Brief Intervention, and Referral to Treatment (SBIRT) embedded within an undergraduate nursing curriculum. Results reveal that students in other schools of nursing would benefit from similar, significant training on substance use disorders and SBIRT. Training satisfaction surveys (N = 488) indicate students were satisfied with the quality of the training experience. More than 90% of students strongly agreed or agreed that the training was relevant to their nursing careers and would help their patients. Additional clinical practice and skill development may increase students' reported effectiveness in working with the topic area of substance use and SBIRT.

Learning Collaboratives: a Strategy for Quality Improvement and Implementation in Behavioral Health.

Learning collaboratives are increasingly used in behavioral health. They generally involve bringing together teams from different organizations and using experts to educate and coach the teams in quality improvement, implementing evidence-based practices, and measuring the effects. Although learning collaboratives have demonstrated some effectiveness in general health care, the evidence is less clear in behavioral health and more rigorous studies are needed. Learning collaboratives may contain a range of elements, and which elements are included in any one learning collaborative varies widely; the unique contribution of each element has not been established. This commentary seeks to clarify the concept of a learning collaborative, highlight its common elements, review evidence of its effectiveness, identify its application in behavioral health, and highlight recommendations to guide technical assistance purveyors and behavioral health providers as they employ learning collaboratives to improve behavioral health access and quality.

Health Facts Medication Adherence in Transplantation (H-MAT) Study: A Secondary Analysis of Determinants and Outcomes of Medication Nonadherence in Adult Kidney Transplant Recipients.

Aims: To explore the relationship between determinants and posttransplant medication nonadherence (MNA) in adult kidney transplant recipients, and to examine the relationship between posttransplant MNA and clinical outcomes. Methods: Using the World Health Organization's model, this retrospective, multicenter, correlational study examined the relationship between determinants, posttransplant MNA, and clinical outcomes in 16,671 adult kidney transplant recipients from the Cerner Health Facts national data warehouse. Results: With 12% MNA, those who were nonadherent were more likely to have the social/economic factors of being younger, single, Caucasian versus Hispanic race, have the condition-related factor of mental health/substance use disorder, and have the healthcare system-related factor of government/health maintenance organization/managed care insurance (p's < 0.05). Bivariate correlations indicated both age (OR = 1.006, p=0.01) and mental health or substance use disorder diagnosis (OR = 1.26, p=0.04) were significant predictors of MNA. Patients were 0.6% more likely to be medication adherent for each year they increased in age and 26% more likely to be MNA if they were diagnosed with a mental health/substance use disorder. Nonadherent patients were less likely to be readmitted, but more likely to have complications after transplant and medication side effects (p's < 0.01). Conclusions: Using one of the largest samples of adult kidney transplant patients, our findings support the WHO model and move the body of medication adherence intervention research forward by clarifying the importance of focusing interventions not only on the patient but on multilevel determinants. Consistent with previous studies, MNA negatively impacts transplant outcomes.

Educator-Informed Development of a Mental Health Literacy Course for School Staff: Classroom Well-Being Information and Strategies for Educators (Classroom WISE).

Educators play a critical role in promoting mental health and well-being with their students. Educators also recognize that they lack knowledge and relevant learning opportunities that would allow them to feel competent in supporting student mental health. As such, educators require resources and training to allow them to develop skills in this area. The Mental Health Technology Transfer Center (MHTTC) Network partnered with the National Center for School Mental Health at the University of Maryland School of Medicine to develop Classroom Well-Being and Information for Educators (WISE), a free, three-part mental health literacy training package for educators and school staff that includes an online course, video library, and resource collection. The Classroom WISE curriculum focuses on promoting positive mental health in the classroom, as well as strategies for recognizing and responding to students experiencing mental health related distress. This paper describes the curriculum development process, including results of focus groups and key informant interviews with educators and school mental health experts. Adoption of Classroom WISE can help educators support student mental health and assist in ameliorating the youth mental health crisis.

The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study.

BACKGROUND: Given substance use disorders (SUDs) among people with HIV are highly prevalent, integrating SUD services within HIV service settings is needed to help end the HIV epidemic. In this study, we assessed the setting-intervention fit (SIF) of 9 evidence-based SUD interventions: acamprosate, disulfiram, oral naltrexone, injectable naltrexone, oral buprenorphine, injectable buprenorphine, contingency management, motivational interviewing, and cognitive behavioral therapy (CBT). SETTING: Clinical and nonclinical HIV service organizations (HSOs) in the United States. METHODS: In May 2020, a stakeholder-engaged real-time Delphi was completed with 202 HSOs. HSO respondents rated the extent to which each SUD intervention was fundable, implementable, retainable, sustainable, scalable, and timely for their HSO, and these 6 items were summed into an SIF score (possible range of 0-18). RESULTS: Motivational interviewing had the highest average SIF score (11.42), with SIF scores above the midpoint (9.5) for clinical (11.51) and nonclinical HSOs (11.36). For nonclinical HSOs, none of the other interventions were above the midpoint. For clinical HSOs, the average SIF scores were above the midpoint for CBT (10.97) and oral buprenorphine (9.51). Multivariate regression analyses, which controlled for characteristics of the HSO respondent, revealed geographic region of the United States and whether the HSO currently offered any substance use services as 2 of the best predictors of SIF scores. CONCLUSIONS: Notwithstanding the need to improve the SIF for the other evidence-based SUD interventions, motivational interviewing, CBT, and oral buprenorphine are currently the evidence-based SUD interventions with greatest perceived fit for integration within HSOs in the United States.

Applying implementation science in mental health services: Technical assistance cases from the Mental Health Technology Transfer Center (MHTTC) network.

OBJECTIVE: Critical gaps exist between implementation of effective interventions and the actual services delivered to people living with mental disorders. Many technical assistance (TA) efforts rely on one-time trainings of clinical staff and printed guidelines that alone are not effective in changing clinical practice. The Mental Health Technology Transfer Center (MHTTC) Network uses implementation science to accelerate the use of evidence-based practices (EBPs), improve performance, and bring about systems-level change. METHOD: Four case examples illustrate how MHTTCs employ the Exploration-Preparation-Implementation-Sustainment (EPIS) implementation framework and intensive implementation strategies to educate clinicians, manage change, and improve processes. These examples include implementing motivational interviewing, cognitive-behavioral therapy for people with psychosis, strategies to decrease the no show rate for virtual appointments, and school mental health systems development. RESULTS: From Preparation through Sustainment, MHTTCs successfully employed implementation strategies including learning communities, audit and feedback, and coaching to bring about change. Each project attended to inner and outer contexts to eliminate barriers. The examples also show the benefit of integrating process improvement alongside implementation. CONCLUSIONS: The MHTTCs are a model for using implementation science to design technical assistance that leads to more successful practical execution of EBPs; thus reducing the gap between research and practice.

Resilience-Focused HIV Care to Promote Psychological Well-Being During COVID-19 and Other Catastrophes.

The COVID-19 pandemic has adversely affected people with HIV due to disruptions in prevention and care services, economic impacts, and social isolation. These stressors have contributed to worse physical health, HIV treatment outcomes, and psychological wellness. Psychological sequelae associated with COVID-19 threaten the overall well-being of people with HIV and efforts to end the HIV epidemic. Resilience is a known mediator of health disparities and can improve psychological wellness and behavioral health outcomes along the HIV Continuum of Care. Though resilience is often organically developed in individuals as a result of overcoming adversity, it may be fostered through multi-level internal and external resourcing (at psychological, interpersonal, spiritual, and community/neighborhood levels). In this Perspective, resilience-focused HIV care is defined as a model of care in which providers promote optimum health for people with HIV by facilitating multi-level resourcing to buffer the effects of adversity and foster well-being. Adoption of resilience-focused HIV care may help providers better promote well-being among people living with HIV during this time of increased psychological stress and help prepare systems of care for future catastrophes. Informed by the literature, we constructed a set of core principles and considerations for successful adoption and sustainability of resilience-focused HIV care. Our definition of resilience-focused HIV care marks a novel contribution to the knowledge base and responds to the call for a multidimensional definition of resilience as part of HIV research.

The implementation and sustainment facilitation strategy improved implementation effectiveness and intervention effectiveness: Results from a cluster-randomized, type 2 hybrid trial.

Background: Substance use disorders (SUDs) among people with HIV are both prevalent and problematic. The Substance Abuse Treatment to HIV care project was funded to test the Implementation and Sustainment Facilitation (ISF) strategy as an adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for SUDs within HIV community-based organizations. Methods: Using a cluster-randomized, type 2 hybrid trial design, 39 HIV organizations were randomized to either (1) ATTC (n = 19) or (2) ATTC + ISF (n = 20). Each HIV organization identified two staff members to be prepared to implement the MIBI (N = 78). Subsequently, during the implementation phase, HIV organizations in each condition randomized client participants (N = 824) to one of the two intervention conditions: usual care (UC; n = 415) or UC + MIBI (n = 409). Both staff-level outcomes and client-level outcomes were examined. Results: The ISF strategy had a significant impact on the implementation effectiveness (i.e., the consistency and the quality of implementation; ß = .65, p = .01) but not on time-to-proficiency (ß = -.02) or level-of-sustainment (ß = .09). In addition, the ISF strategy was found to have a significant impact on the intervention effectiveness (the effectiveness of the MIBI), at least in terms of significantly decreasing the odds (odds ratio = 0.11, p = .02) of clients using their primary substance daily during follow-up. Conclusion: The ISF strategy was found to be an effective adjunct to the ATTC strategy in terms of implementation effectiveness and intervention effectiveness. It is recommended that future efforts to integrate the project's MIBI for SUD within HIV organizations use the ATTC + ISF strategy. However, given the ISF strategy did not have a significant impact on level-of-sustainment, implementation research testing the extent to which the ATTC + ISF strategy can be significantly enhanced through effective sustainment strategies is warranted. Plain language abstract: Substance use among people living with HIV is associated with increased mental health problems, worse medication adherence, and worse HIV viral suppression. Increasing substance use-related services in HIV community-based organizations is an important public health need. The Substance Abuse Treatment to HIV care project tested two strategies for helping HIV organizations implement a brief intervention (BI) designed to motivate clients to decrease their substance use. The project also tested if receiving a BI improved clients' outcome. Two staff from each of the 39 participating organizations were taught how to deliver the BI using the Addiction Technology Transfer Center (ATTC) training strategy (online and in-person training, monthly feedback, and coaching). Half of the organizations also received the Implementation and Sustainment Facilitation (ISF) strategy, which included monthly meetings with an ISF coach for the two BI staff and one or more leadership staff from the organization. Organizations that received both the ATTC and ISF strategies delivered more BIs and higher quality BIs than organizations that only received the ATTC strategy. In addition, clients receiving BIs at organizations that received both strategies were more likely to decrease their substance use. However, receiving both strategies did not improve how quickly staff learned to deliver the BI or improve the number of BIs delivered during the project's 6-month sustainment phase. Future research focused on implementing BIs within HIV organizations should consider using the ATTC and ISF strategies while also seeking to enhance the strategies to improve sustainment.

Victimization among African-American adolescents in substance abuse treatment.

Victimization is regarded as a significant public health issue, especially among adolescents in urban areas. Although victimization is linked to substance use, the research on victimization among adolescents in treatment is underdeveloped. Given the high rate of victimization among African-American adolescents, further research on the prevalence and correlates of victimization for this population is needed. This knowledge can guide the development of effective treatment and prevention strategies. This study contributed to the research by examining the rate and different types of victimization among a sample of African-American adolescents in an urban substance abuse treatment program, testing whether victimization is associated with increased levels of psychopathology and high-risk behaviors; and comparing the rates and associations with existing studies of adolescent victimization. It reports on a sample of 259 African-American adolescents receiving substance abuse treatment in an inner-city program. Fifty-four percent of the subjects reported lifetime victimization. Severity of victimization was associated with depression, generalized anxiety disorder, traumatic stress disorder, and conduct disorder, although the effect sizes were relatively small. Lifetime victimization exhibited a relationship of small to moderate strength with high-risk behaviors (i.e., illegal activity, gang membership, multiple sex partners and unprotected sex). Service implications and recommendations for future research are provided.

An implementation story: moving the GAIN from pilot project to statewide use.

Similar to implementing an evidence-based practice (EPB), implementing an evidence-based assessment (EBA) is a long, complex process that can take several years to complete. Between 2002 and 2007, the state of Missouri first piloted the Global Appraisal of Individual Needs-Initial (GAIN-I; Dennis et al. 2006) assessment at one state-contracted adolescent substance abuse treatment program and then implemented the GAIN statewide. This case study documents the implementation process through Fixsen and colleagues' (2005) six stages of implementation, from exploration and adoption through sustainability, and outlines challenges and solutions encountered at the external, organizational, and individual staff level. Strengths of this project included recognition that implementation is an ongoing multistep process, strong support by state-level staff, contracting with an external purveyor for ongoing technical assistance at the agency level as well as training of front-line clinicians, and an implementation team comprised of stakeholders at multiple levels.

Distance Versus On-Site Educational Strategies for Competency-Based Screening, Brief Intervention, and Referral to Treatment Education.

BACKGROUND: Although the individual and public health consequences of alcohol and drug use are substantial, nursing education programs generally lack content on addiction. The goal of this evaluation was to compare the initial outcomes of on-site versus distance methods for training graduate nurse practitioner students in Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use. METHOD: A nonrandomized two-group pretest-posttest design was used to compare knowledge, attitudes, and skills learning outcomes between on-site (n = 45) and distance (n = 18) family or adult/geriatric Master of Science in Nursing nurse practitioner students receiving SBIRT training. RESULTS: Overall, students increased their knowledge, attitudes, and confidence about screening and intervening with patients who use substances; showed a high level of skills in conducting a brief intervention to motivate patients to reduce their substance use; and were highly satisfied with the education provided. Counseling confidence and gains in knowledge were similar across groups. Compared with distance students, on-site students reported significantly more positive attitudes about their role adequacy, role legitimacy, and role support for intervening with alcohol use and about their role support for intervening with drug use. On-site students had greater training satisfaction, but distance students' skills assessed through standardized patient interactions were significantly better. CONCLUSIONS: Both on-site and distance training were effective instructional methods to increase SBIRT knowledge and skills. However, differences in attitudes, training satisfaction, and skills demonstration should be taken into account when designing addiction training using distance technologies.

Correction to: Testing the effectiveness of a motivational interviewing-based brief intervention for substance use as an adjunct to usual care in community-based AIDS service organizations: study protocol for a multisite randomized controlled trial.

Upon publication of the original article.

Testing the implementation and sustainment facilitation (ISF) strategy as an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy: study protocol for a cluster randomized trial.

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.