Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (helping end addiction long-term®) communities study.

BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

Alternatives to dental opioid prescribing after tooth extraction (ADOPT): protocol for a stepped wedge cluster randomized trial.

BACKGROUND: Dentists and oral surgeons are leading prescribers of opioids to adolescents and young adults (AYA), who are at high risk for developing problematic opioid use after an initial exposure. Most opioids are prescribed after tooth extraction, but non-opioid analgesics provide similar analgesia and are recommended by multiple professional organizations. METHODS: This multi-site stepped wedge cluster-randomized trial will assess whether a multicomponent behavioral intervention can influence opioid prescribing behavior among dentists and oral surgeons compared to usual practice. Across up to 12 clinical practices (clusters), up to 33 dentists/oral surgeons (provider participants) who perform tooth extractions for individuals 12-25 years old will be enrolled. After enrollment, all provider participants will receive the intervention at a time based on the sequence to which their cluster is randomized. The intervention consists of prescriber education via academic detailing plus provision of standardized patient post-extraction instructions and blister packs of acetaminophen and ibuprofen. Provider participants will dispense the blister packs and distribute the patient instructions at their discretion to AYA undergoing tooth extraction, with or without additional analgesics. The primary outcome is a binary, patient-level indicator of electronic post-extraction opioid prescription. Data for the primary outcome will be collected from the provider participant's electronic health records quarterly throughout the study. Provider participants will complete a survey before and approximately 3 months after transitioning into the intervention condition to assess implementation outcomes. AYA patients undergoing tooth extraction will be offered a survey to assess pain control and satisfaction with pain management in the week after their extraction. Primary analyses will use generalized estimating equations to compare the binary patient-level indicator of being prescribed a post-extraction opioid in the intervention condition compared to usual practice. Secondary analyses will assess provider participants' perceptions of feasibility and appropriateness of the intervention, and patient-reported pain control and satisfaction with pain management. Analyses will adjust for patient-level factors (e.g., sex, number of teeth extracted, etc.). DISCUSSION: This real-world study will address an important need, providing information on the effectiveness of a multicomponent intervention at modifying dental prescribing behavior and reducing opioid prescriptions to AYA. CLINICALTRIALS: GOV: NCT06275191.

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.

Longitudinal trends in nonmedical prescription opioid use in a cohort of rural Appalachian people who use drugs.

Rural Appalachia remains an epicenter of the prescription opioid epidemic. In 2008, a cohort study was undertaken to examine longitudinal trends in nonmedical prescription opioid use (NMPOU). Eight waves of data (2008-2020) from the Social Networks among Appalachian People (SNAP) cohort were utilized for the current analysis. Only those who reported recent (past 6-month) NMPOU at baseline are included (n = 498, 99%). Mixed-effects logistic regression was used to model factors associated with NMPOU over time. Recent NMPOU declined significantly over the past decade (p < .001). However, 54.1% of participants still engaged in NMPOU at their most recent follow-up. Receipt of benefits for a physical or mental disability (adjusted odds ratio [aOR]: 3.11, 95% Confidence Interval [CI]: 1.98, 4.90) and self-described poor health status (aOR: 3.67, 95% CI: 1.61, 8.37) were both associated with NMPOU. All treatment modalities (methadone maintenance, residential, outpatient counseling) tested in the model, with the notable exception of detoxification, were associated with significantly lower odds of NMPOU. Although significant declines in prescription opioid misuse were observed in the cohort, more than half of all participants were engaged in NMPOU more than a decade after entering the study. Substance use disorder (SUD) treatment (excluding detoxification) was shown associated with reduced odds of continued NMPOU; therefore, increasing access to evidence-based treatments should be a priority in rural areas affected by the ongoing opioid epidemic.

Adoption of the 275-patient buprenorphine treatment waiver for treating opioid use disorder: A state-level longitudinal analysis.

Background: Increasing access to buprenorphine treatment is a critical tool for addressing the opioid epidemic in the United States. In 2016, a federal policy change allowed physicians who meet specific requirements to treat up to 275 concurrent buprenorphine patients. This study examines state-level measures of buprenorphine treatment supply over 21 months since this policy change and estimates associations between the supply of 275-patient waivers and state characteristics. Methods: Monthly state-level measures of the number of physicians holding the 275-patient waiver per 100,000 residents were constructed from September 2016 to May 2018 using the Drug Enforcement Agency's Controlled Substance Act database. State characteristics were obtained from publicly available sources. Mixed-effects regression models were estimated to examine change over time. Results: During the 21-month period, the number of physicians waivered to treat 275 patients increased from 153 to 4009 physicians. The mean supply of 275-patient physicians per 100,000 state residents significantly increased from 0.07 (SD = 0.21) in September 2016 to 1.43 (SD = 1.08) in May 2018 (t = -9.84, df = 50, P < .001). The final mixed-effects regression model indicated that Census division and the preexisting supply of 100-patient waivered physicians were correlated with the rate of growth in 275-patient waivers over the study period. Conclusions: Although uptake of the 275-patient waiver has exceeded initial projections, growth is uneven across the United States. Unequal patterns of growth pose a challenge to efforts to increase treatment availability as a means of addressing the opioid epidemic.

A preliminary examination of substance use risk among metropolitan and non-metropolitan girls involved in the juvenile justice system.

Research is limited on geographic differences in substance use risk factors among juvenile justice-involved girls. This secondary data analysis from one state juvenile justice system, collected as part of the NIH/NIDA funded JJTRIALS cooperative agreement, assessed criminogenic needs at intake for 160 girls from metropolitan and non-metropolitan counties. Although girls from different geographic areas did not differ significantly on key variables of interest, including substance use risk and related criminality variables, findings suggest that substance use risk is related to criminal history, substance-related offenses, and relationship problems among justice-involved girls. Implications include gender-specific juvenile justice programming and research.

Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States.

PURPOSE: Although there is a tremendous need to increase the use of buprenorphine for the treatment of opioid use disorder in rural areas, little is known about current rural/urban differences in treatment practices. We aimed to examine physician characteristics, treatment practices, and concordance with treatment guidelines among buprenorphine prescribers across different locations of practice. METHODS: A national random sample of buprenorphine physician prescribers was surveyed (n = 1,174, response rate = 33%) from July 2014 to January 2017. Analyses examined buprenorphine treatment across locations of practice (categorized as nonmetropolitan, small metropolitan, and large metropolitan). RESULTS: Among buprenorphine prescribers surveyed, 11.2% (n = 132) practiced in nonmetropolitan/rural areas, 32.5% (n = 382) in small metropolitan areas, and 56.2% (n = 660) in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including induction, frequency of visits, dosing, and use of psychosocial treatment, which were generally consistent with buprenorphine treatment recommendations. CONCLUSIONS: There are important differences in characteristics of buprenorphine prescribers in nonmetropolitan areas compared with more urban areas, including the fact that the majority of nonmetropolitan physicians are primary care physicians. Although treatment access in rural areas is an ongoing challenge, buprenorphine treatment practices are similar. Understanding buprenorphine prescribers and their treatment practices may help inform tailored strategies to address treatment needs in different locations.

Smokeless Tobacco and the Rural Teen: How Culture and Masculinity Contribute to Adolescent Use.

Tobacco use is the leading preventable cause of disease, disability, and death in the United States. Smokeless tobacco (SLT) is primarily used by younger, rural males and often in the presence of other males. This formative study examined how hegemonic masculinity and male norms can lead to initiation and continued use of SLT by rural adolescent males and females. Survey data collected from high school sophomores in 4 rural high schools (n = 293) explores perceptions of masculinity and male norms' contribution to SLT uptake and use. About 22.5% of total sample reported lifetime use (34.4% male, 13.7% female), 10.9% reported past-month use (20.0% male, 4.2% female). Logistic regressions show a one-unit increase in adherence to traditional perceptions of masculinity more than doubled the odds of ever using SLT and significantly increased odds of 30-day use. Having male household family members who uses SLT significantly increased the odds of lifetime and 30-day SLT use for both genders, while having male family members who smoke cigarettes was not a significant correlate. Recognition of health warnings on SLT packaging was negatively associated with SLT use for both genders. Implications for inclusion of masculinity and male role models in SLT prevention intervention strategies are discussed.

Implementation of smoking cessation treatment in substance use disorder treatment settings: a review.

BACKGROUND: The high prevalence of smoking among individuals receiving treatment for substance use disorder (SUD) has led to repeated calls for integrating smoking cessation treatment into these settings. OBJECTIVES: This review summarizes key findings from the research on the implementation of smoking cessation in SUD treatment. METHODS: PubMed searches of articles published from 2000 to 2015 yielded 48 empirical studies that focused on the delivery of smoking cessation in the US specialty SUD treatment settings in which organizations and counselors were the unit of analysis. Most studies used observational designs to gather data from organizations and counselors. Organizational studies show that few SUD treatment programs offer cessation counseling or pharmacotherapy. Organizational barriers include limited training, inadequate resources, and cultural norms that do not recognize smoking cessation as part of the organization's mission. Smoking cessation services are more likely to be available in medically oriented treatment settings, larger treatment programs, those offering a broader array of comprehensive services, and those that are more reliant on fee-for-service reimbursement (e.g., insurance, Medicaid). Surveys of counselors also show very low implementation. Counselors' personal skills and attitudes, their perceptions of managerial and coworker support for smoking cessation, and the availability of resources and reimbursement to support these services are correlated with implementation. State policies requiring treatment programs to offer tobacco treatment increase both adoption and implementation, yet these services continue to reach only modest percentages of the patients. CONCLUSIONS: Few studies have tested specific implementation strategies. Such research is needed to determine how to accelerate the diffusion of these evidence-based practices to the SUD treatment field.

Service delivery and pharmacotherapy for alcohol use disorder in the era of health reform: Data from a national sample of treatment organizations.

BACKGROUND: Although there is a growing literature examining organizational characteristics and medication adoption, little is known about service delivery differences between specialty treatment organizations that have and have not adopted pharmacotherapy for alcohol use disorder (AUD). This study compares adopters and nonadopters across a range of treatment services, including levels of care, availability of tailored services for specific populations, treatment philosophy and counseling orientations, and adoption of comprehensive wraparound services. METHODS: In-person interviews were conducted with program leaders from a national sample of 372 organizations that deliver AUD treatment services in the United States. RESULTS: About 23.6% of organizations had adopted at least 1 AUD medication. Organizations offering pharmacotherapy were similar to nonadopters across many measures of levels of care, tailored services, treatment philosophy, and social services. The primary area of difference between the 2 groups was for services related to health problems other than AUD. Pharmacotherapy adopters were more likely to offer primary medical care, medications for smoking cessation, and services to address co-occurring psychiatric conditions. CONCLUSIONS: Service delivery differences were modest between adopters and nonadopters of AUD pharmacotherapy, with the exception of health-related services. However, the greater adoption of health-related services by organizations offering AUD pharmacotherapy represents greater medicalization of treatment, which may mean these programs are more strongly positioned to respond to opportunities for integration under health reform.

Effects of an Organizational Linkage Intervention on Inter-Organizational Service Coordination Between Probation/Parole Agencies and Community Treatment Providers.

Weak coordination between community correctional agencies and community-based treatment providers is a major barrier to diffusion of medication-assisted treatment (MAT)--the inclusion of medications (e.g., methadone and buprenorphine) in combination with traditional counseling and behavioral therapies to treat substance use disorders. In a multisite cluster randomized trial, experimental sites (j = 10) received a 3-h MAT training plus a 12-month linkage intervention; control sites (j = 10) received the 3-h training alone. Hierarchical linear models showed that the intervention resulted in significant improvements in perceptions of interagency coordination among treatment providers, but not probation/parole agents. Implications for policy and practice are discussed.

Reducing risky relationships: a multisite randomized trial of a prison-based intervention for reducing HIV sexual risk behaviors among women with a history of drug use.

Women involved in the criminal justice system, particularly those with a history of drug use, are at elevated risk of HIV infection, yet few HIV prevention interventions have been tailored for delivery to incarcerated women. Drawing on the Relational Model, the Reducing Risky Relationships for HIV (RRR-HIV) intervention was developed and evaluated in a multisite randomized clinical trial. Women with weekly drug use prior to incarceration (n = 444) who were incarcerated within correctional institutions in four states were randomized to (1) the RRR-HIV intervention consisting of an HIV educational video, five group sessions, and one postrelease booster session or (2) a control condition consisting of the HIV educational video. The RRR-HIV intervention combined didactic and interactive content regarding seven "thinking myths" about intimate relationships that may result in decisions to engage in risky sexual behaviors. Data were collected while women were still incarcerated and approximately 90 days following release from prison by trained interviewers. A negative binomial regression (NBR) model of unprotected sexual behaviors at the 90-day follow-up indicated that RRR-HIV participants reported fewer unprotected sexual behaviors than women in the control condition once the analysis was adjusted for study site. Future studies should examine the sustainability of the RRR-HIV intervention's effect on risk reduction. Implementation research is needed to determine whether delivery of this intervention by correctional staff or peers, rather than research staff, yields similar reductions in unprotected sexual behaviors.

The influence of familial networks and stigma on prison-based medication initiation for individuals with opioid use disorder: Clinicians' perceptions.

INTRODUCTION: Individuals with criminal legal system (CLS) involvement experience opioid use disorder (OUD) at elevated rates when compared to their non-justice involved counterparts. Medications for opioid use disorder (MOUD) are efficacious but underutilized within this population. Interpersonal relationships and stigma play salient roles in the outcomes of OUD treatment. This study examines prison-based treatment staff perspectives on how familial networks and stigma interact to impact one's decision of whether to initiate MOUD while in prison in Kentucky. METHODS: A coding team analyzed qualitative interviews with prison-based clinicians (n = 23) and administrators (n = 9) collected from the Geographic variation in Addiction Treatment Experiences (GATE) study using NVivo software. The study analyzed excerpts associated with the primary codes of "stigma" and "social networks" and the secondary code of "family" in order to assess the relationship between familial stigma and MOUD initiation from treatment staff viewpoints. RESULTS: Arising themes suggest that clients' families' lack of MOUD knowledge plays a crucial role in perpetuating related stigma, that this stigma often materializes as a belief that MOUD is a continuation of illicit substance use and that stigma levels vary across MOUD forms (e.g., more stigma towards agonists than antagonists). CONCLUSIONS: These findings carry implications for better understanding how intervention stigma within one's familial network impacts prison-based medication initiation decisions. Resulting themes suggest support for continued expansion of efforts by Kentucky Department of Corrections to involve participant families in education and treatment initiatives to reduce intervention stigma and increase treatment utilization.

Equity of overdose education and naloxone distribution provided in the Kentucky HEALing Communities Study.

Background: Opioid overdoses differentially affect demographic groups. Strategies to reduce overdose deaths, specifically overdose education and naloxone distribution (OEND), are not consistently delivered equitably. Methods: The HEALing Communities StudySM (HCS) is a cluster-randomized trial designed to implement evidence-based practices, including OEND, to reduce overdose deaths across communities. Individuals receiving OEND in eight Kentucky counties between January 2020 and June 2022 provided demographics and overdose history. Recipient characteristics were compared to opioid overdose decedent characteristics to evaluate whether OEND was equitably delivered to the target population. Recipient characteristics were also analyzed based on whether OEND was delivered in criminal justice, behavioral health, or health care facilities. Results: A total of 26,273 demographic records were analyzed from 137 partner agencies. Most agencies were in behavioral health (85.6 %) or criminal justice sectors (10.4 %). About half of OEND recipients were male (50.6 %), which was significantly lower than the 70.3 % of overdose decedents who were male, (p<0.001). OEND recipients tended to be younger than overdose decedents, but there were not significant differences in race/ethnicity between OEND recipients and overdose decedents. Over 40 % of OEND recipients had overdosed, and 68.9 % had witnessed a prior overdose. There were notable differences across facility types, as males and Black individuals accounted for fewer OEND recipients in addiction treatment facilities compared to jails. Conclusion: Although OEND recipients' demographics resembled those of decedents, specific attention should be paid to ensuring equitable OEND access. Variation in OEND uptake by facility type may reflect biases and barriers to care.

Rural and urban clinician views on COVID-19's impact on substance use treatment for individuals on community supervision in Kentucky.

BACKGROUND: The COVID-19 pandemic produced system-level changes within the criminal legal system and community-based substance use disorder (SUD) treatment system with impacts on recovery efforts. This study examines rural and urban clinicians' perspectives of COVID-19 on SUD treatment delivery for people on community supervision. METHODS: Virtual qualitative interviews were conducted between April and October 2020 with 25 community supervision clinicians employed by Kentucky's Department of Corrections (DOC), who conduct assessments and facilitate community-based treatment linkages for individuals on probation or parole. Transcripts were analyzed in NVivo using directed content analysis methods. RESULTS: Clinicians were predominantly white (92%) and female (88%) with an average of over 9 years working in the SUD treatment field and 4.6 years in their current job. Four COVID-19 themes were identified by both rural and urban clinicians including: (1) telehealth increases the modes of communication, but (2) also creates paperwork and technological challenges, (3) telehealth requires more effort for inter/intra-agency collaboration, and (4) it limits client information (e.g., no urine drug screens). Two additional rural-specific themes emerged related to COVID-19: (5) increasing telehealth options removes SUD treatment transportation barriers and (6) requires flexibility with programmatic requirements for rural clients. CONCLUSIONS: Findings indicate the need for community-based SUD treatment providers approved or contracted by DOC to support and train clients to access technology and improve information-sharing with community supervision officers. A positive lesson learned from COVID-19 transitions was a reduction in costly travel for rural clients, allowing for greater engagement and treatment adherence. Telehealth should continue to be included within the SUD continuum of care, especially to promote equitable services for individuals from rural areas.

Rapid jail-based implementation of overdose education and naloxone distribution in response to the COVID-19 pandemic.

BACKGROUND: People incarcerated in jails are highly impacted by the opioid epidemic, and overdose education and naloxone distribution (OEND) is an effective strategy to reduce opioid overdose deaths. This study examines barriers and facilitators of fast-track OEND implementation within the jails in the Wave 1 Kentucky counties of the HEALing Communities Study during the COVID-19 pandemic. METHODS: Meeting minutes with jail stakeholders were qualitatively coded using the Practical, Robust Implementation and Sustainability Model (PRISM) as the coding framework. The analysis highlighted the top barriers and facilitators to fast-track OEND implementation within the PRISM framework. RESULTS: Space and staffing shortages related to the COVID-19 pandemic, disruptions in interorganizational programming from pandemic-related service suspensions, and a lack of technological solutions (e.g., reliable Internet access) for socially distanced delivery were the top barriers to fast-track OEND implementation. In addition, there were limitations on non-jail staff access to jails during COVID-19. Top facilitators included jail leadership support, the option to prioritize high-risk groups, and the incorporation of OEND processes into existing communications and management software. While the COVID-19 pandemic strained jail infrastructure, jail and partner agency collaboration led to creative implementation strategies for the successful integration of OEND into jail operations. Urban jails were more likely than rural jails to be early adopters of OEND during the public health emergency. CONCLUSIONS: Understanding the barriers to and facilitators of OEND within jails will improve implementation efforts seeking to curb opioid overdose deaths. Jail leadership support and interorganizational efforts were key facilitators to implementation; therefore, it is recommended to increase buy-in with multiple agencies to promote success. Challenges brought on by COVID-19 have resulted in a need for innovative solutions for implementation. CLINICAL TRIAL INFORMATION: ClinicalTrials.gov, NCT04111939, Submitted 30 September 2019, https://clinicaltrials.gov/study/NCT04111939?titles=HEALing%20Communities%20Study&rank=1 .

Differences in perceptions of community stigma towards opioid use disorder between community substance use coalition members and the general public.

INTRODUCTION: To examine differences in perceptions about community stigma towards individuals with opioid use disorder (OUD) between community members involved in the opioid response (i.e., coalition members) and the general public, and how community geography may moderate this relationship. METHODS: This study administered identical cross-sectional surveys about perceived community opioid-related stigma to two distinct populations in 66 communities participating in the HEALing Communities Study prior to the intervention period (i.e., coalition members, November 2019-January 2020; residents, March-April 2020). Linear-mixed models compared survey responses of populations, including the moderating effect of community rural/urban location. RESULTS: A total of 826 coalition members and 1131 residents completed the surveys. The study found no differences between the coalition members and residents for general perceived community opioid-related stigma. In both urban and rural communities, coalition members reported greater perceived community stigma than residents reported towards medication for opioid use disorder (MOUD), naloxone, and drug treatment as an alternative to incarceration. CONCLUSION: Our findings suggest similar perceived community opioid-related stigma between coalition members and residents, yet differences emerge related to evidence-based practices (i.e., MOUD, naloxone, and drug treatment as an alternative to incarceration) to reduce opioid overdose deaths. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04111939.

Effects of the Communities that Heal (CTH) intervention on perceived opioid-related community stigma in the HEALing Communities Study: results of a multi-site, community-level, cluster-randomized trial.

Background: Community stigma against people with opioid use disorder (OUD) and intervention stigma (e.g., toward naloxone) exacerbate the opioid overdose crisis. We examined the effects of the Communities that HEAL (CTH) intervention on perceived opioid-related community stigma by stakeholders in the HEALing Communities Study (HCS). Methods: We collected three surveys from community coalition members in 66 communities across four states participating in HCS. Communities were randomized into Intervention (Wave 1) or Wait-list Control (Wave 2) arms. We conducted multilevel linear mixed models to compare changes in primary outcomes of community stigma toward people treated for OUD, naloxone, and medication for opioid use disorder (MOUD) by arm from time 1 (before the start of the intervention) to time 3 (end of the intervention period in the Intervention arm). Findings: Intervention stakeholders reported a larger decrease in perceived community stigma toward people treated for OUD (adjusted mean change (AMC) -3.20 [95% C.I. -4.43, -1.98]) and toward MOUD (AMC -0.33 [95% C.I. -0.56, -0.09]) than stakeholders in Wait-list Control communities (AMC -0.18 [95% C.I. -1.38, 1.02], p = 0.0007 and AMC 0.11 [95% C.I. -0.09, 0.31], p = 0.0066). The relationship between intervention status and change in stigma toward MOUD was moderated by rural-urban status (urban AMC -0.59 [95% CI, -0.87, -0.32], rural AMC not sig.) and state. The difference in stigma toward naloxone between Intervention and Wait-list Control stakeholders was not statistically significant (p = 0.18). Interpretation: The CTH intervention decreased stakeholder perceptions of community stigma toward people treated for OUD and stigma toward MOUD. Implementing the CTH intervention in other communities could decrease OUD stigma across diverse settings nationally. Funding: US National Institute on Drug Abuse.

Sustainment of smoking cessation programs in substance use disorder treatment organizations.

INTRODUCTION: The majority of individuals who enter substance use disorder (SUD) treatment also use tobacco. Integrating smoking cessation services into SUD treatment may have substantial public health benefits, but few studies have examined whether organizations offering counseling-based smoking cessation programs sustain them over time. METHODS: This study examines sustainment of smoking cessation programs using 2 waves of data collected from 150 SUD treatment organizations. Data were collected in 2006-2008 and 2009-2010 using face-to-face interviews, telephone interviews, and mailed surveys. Logistic regression models of sustainment were estimated with administrators' attitudes toward smoking cessation and organizational barriers as covariates. RESULTS: About 60.2% of these SUD treatment organizations sustained their counseling-based smoking cessation programs at follow-up. Sustainment was significantly more likely when administrators' baseline attitudes about the impact of smoking cessation on recovery were more supportive (odds ratio, OR = 1.84; 95% confidence interval, CI = 1.13-3.01; p =.015) and when programs were accredited (OR = 3.95, 95% CI = 1.65-9.50, p =.002). Worsening over time of barriers encompassing staff interest, staff skills, and competing treatment demands were negatively associated with sustainment (OR = 0.58, 95% CI = 0.42-0.81, p =.001). CONCLUSIONS: These findings provided empirical support for theoretical perspectives regarding the importance of leadership and staff expertise in promoting sustainment of innovations over time. Although the majority of SUD treatment organizations sustained their smoking cessation programs, the 40% rate of discontinuation is concerning and highlights the ongoing challenges faced by tobacco control efforts in substance abuse treatment.

Barriers and facilitators to the use of medication for opioid use disorder within the criminal justice system: Perspectives from clinicians.

INTRODUCTION: This study examines social service clinicians' (SSCs) perspectives of factors within the criminal justice system that impact justice-involved individuals' use of medications for opioid use disorder (MOUD). Opioid use disorder (OUD) rates are high among justice-involved individuals, and overdose risk is heightened upon release from incarceration. This study is innovative, as it specifically focuses on criminal justice contexts that influence the MOUD continuum of care from the perspective of clinicians working within the criminal justice system. Understanding criminal justice-related facilitators and barriers to MOUD treatment will guide tailored policy intervention to increase MOUD use and promote recovery and remission among justice-involved individuals. METHODS: The study completed qualitative interviews with 25 SSCs who are employed by a state department of corrections to provide assessment and referrals to substance use treatment to individuals on community supervision. The study used NVivo software to code the major themes found within each transcribed interview; two research assistants participated in consensus coding to ensure consistency in coding across transcripts. This study focused on the secondary codes that fell under the "Criminal Justice System" primary code, as well as codes that indicated barriers and facilitators to MOUD treatment. RESULTS: SSCs cited sentencing time credits as structural facilitators of MOUD treatment; clients sought more information about extended-release naltrexone since time off of their sentence was available if initiated. Support for extended-release naltrexone by officers and judges was often mentioned as an attitudinal facilitator of initiation. Poor intra-agency collaboration among department of corrections agents was an institutional barrier to MOUD. Also, probation and parole officers' stigma surrounding other types of MOUD, specifically buprenorphine and methadone, was an attitudinal barrier to MOUD within the criminal justice system. CONCLUSIONS: Future research should examine the effect that time credits have on extended-release naltrexone initiation, considering the wide consensus among SSCs that their clients were motivated to initiate this type of MOUD because of the resulting time off their sentences. Stigma among probation and parole officers and lack of communication within the criminal justice system need to be addressed so that more individuals with OUD may be exposed to life-saving treatments.