Prevention of Opioid Use and Disorder Among Youth Involved in the Legal System: Innovation and Implementation of Four Studies Funded by the NIDA HEAL Initiative.

Youth involved in the legal system (YILS) experience rates of opioid and substance use disorders (OUD/SUDs) and overdose that is well above those in the general population. Despite the dire need, and the existing programs that focus on treatment of these problems in YILS, research on opioid initiation, and OUD prevention, including feasibility and sustainability, are severely limited. We present four studies testing interventions that, while not necessarily novel as SUD treatments, test novel structural and interpersonal strategies to prevent opioid initiation/OUD precursors: (1) ADAPT (Clinical Trial No. NCT04499079) provides real-time feedback using community-based treatment information system data to create a more effective mental health and SUD treatment cascade to prevent opioid use; (2) HOME (Clinical Trial No. NCT04135703) provides youth experiencing homelessness, including YILS, with direct access to shelter in independent living without prerequisites as an opioid initiation prevention strategy; (3) LeSA (Clinical Trial No. NCT04678960) uses the Trust-Based Relational Intervention® to equip YILS and their caregivers with self-regulatory and communication skills during the transition from secure confinement to reduce opioid initiation/re-initiation; and (4) POST (Clinical Trial No. NCT04901312) tests two interventions integrating interpersonal/drinking and drug refusal skills, case management, and goal setting among YILS in transitioning out of secure detention as opioid initiation prevention strategies. We discuss early implementation barriers and facilitators, including complexities of prevention research with YILS and adaptations due to COVID-19. We conclude by describing anticipated end products, including implementation of effective prevention interventions and integration of data from multiple projects to address larger, multi-site research questions.

Methodological Strategies for Prospective Harmonization of Studies: Application to 10 Distinct Outcomes Studies of Preventive Interventions Targeting Opioid Misuse.

The Helping to End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is rapidly developing 10 distinct evidence-based interventions for implementation in a variety of settings to prevent opioid misuse and opioid use disorder. One HPC objective is to compare intervention impacts on opioid misuse initiation, escalation, severity, and disorder and identify whether any HPC interventions are more effective than others for types of individuals. It provides a rare opportunity to prospectively harmonize measures across distinct outcomes studies. This paper describes the needs, opportunities, strategies, and processes that were used to harmonize HPC data. They are illustrated with a strategy to measure opioid use that spans the spectrum of opioid use experiences (termed involvement) and is composed of common "anchor items" ranging from initiation to symptoms of opioid use disorder. The limitations and opportunities anticipated from this approach to data harmonization are reviewed. Lastly, implications for future research cooperatives and the broader HEAL data ecosystem are discussed.

Avoidance Self-Efficacy: Personal Indicators of Risky Sex and Substance Use among At-Risk Youth.

Adolescent substance use (SU) is associated with risky sex behavior and sexually transmitted infections and is a risk factor for subsequent risky sex decisions. Based on a sample of 1,580 youth in residential SU treatment, this study investigated how a static factor (race) and two dynamic personal factors (risk-taking, assertiveness) contributed to adolescents' perceived ability to avoid high-risk SU and sex behavior (avoidance self-efficacy). Results showed that race correlated with risk-taking and assertiveness, with White youth reporting higher ratings of assertiveness and risk-taking. Self-reported assertiveness and risk-taking also predicted SU and risky sex avoidance. This study underscores the importance of race and personal factors in relation to adolescents' confidence in avoiding high-risk situations.

The comparative effectiveness of Core versus Core+Enhanced implementation strategies in a randomized controlled trial to improve substance use treatment receipt among justice-involved youth.

BACKGROUND: Most justice-involved youth are supervised in community settings, where assessment and linkage to substance use (SU) treatment services are inconsistent and fragmented. Only 1/3 of youth with an identified SU need receive a treatment referral and even fewer initiate services. Thus, improving identification and linkage to treatment requires coordination across juvenile justice (JJ) and behavioral health (BH) agencies. The current study examines the comparative effectiveness of two bundled implementation intervention strategies for improving SU treatment initiation, engagement, and continuing care among justice-involved youth supervised in community settings. Exploration, Preparation, Implementation, Sustainment (EPIS) served as the conceptual framework for study design and selection/timing of implementation intervention components, and the BH Services Cascade served as the conceptual and measurement framework for identifying and addressing gaps in service receipt. METHODS: Part of a larger Juvenile-Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) Cooperative, this study involved a multisite, cluster-randomized control trial where sites were paired then randomly assigned to receive Core (training teams on the BH Services Cascade and data-driven decision making; supporting goal selection) or Core+Enhanced (external facilitation of implementation teams) intervention components. Youth service records were collected from 20 JJ community supervision agencies (in five states) across five study phases (baseline, pre-randomization, early experiment, late experiment, maintenance). Implementation teams comprised of JJ and BH staff collaboratively identified goals along the BH Cascade and used data-driven decision-making to implement change. RESULTS: Results suggest that Core intervention components were effective at increasing service receipt over time relative to baseline, but differences between Core and Core+Enhanced conditions were non-significant. Time to service initiation was shorter among Core+Enhanced sites, and deeper Cascade penetration occurred when external facilitation (of implementation teams) was provided. Wide variation existed in the degree and nature of change across service systems. CONCLUSIONS: Findings demonstrate the criticality of early EPIS phases, demonstrating that strategies provided during the formative exploration and preparation phases produced some improvement in service receipt, whereas implementation-focused activities produced incremental improvement in moving youth farther along the Cascade.

Improving Substance Use Services for Juvenile Justice-Involved Youth: Complexity of Process Improvement Plans in a Large Scale Multi-site Study.

Despite the high prevalence of substance use disorders among juvenile offenders, most do not receive services. System-level process improvement plans to address unmet service needs can be optimized by combining data-driven decisions and facilitated meetings with behavioral health stakeholders. This paper operationalizes and analyzes the level of specified complexity among process improvement plans evident within 36 juvenile probation and drug courts across 7 states. To inform more effective implementation strategies, this analysis identifies and prioritizes promising courses of agency enhancement toward addressing unmet substance use needs.

Evidence Base on Outpatient Behavioral Treatments for Adolescent Substance Use, 2014-2017: Outcomes, Treatment Delivery, and Promising Horizons.

This article updates the evidence base on outpatient behavioral treatments for adolescent substance use (ASU) since publication of the previous review completed for this journal by Hogue, Henderson, Ozechowski, and Robbins (2014). It first summarizes the Hogue et al. findings along with those from recent literature reviews and meta-analytic studies of ASU treatments. It then presents study design and methods criteria used to select 11 comparative studies subjected to Journal of Clinical Child and Adolescent Psychology level of support evaluation. These 11 studies are detailed in terms of their sample characteristics, methodological quality, and substance use outcomes. Cumulative level of support designations are then made for each identified treatment approach. These cumulative designations are virtually identical to those of the previous review: ecological family-based treatment, individual cognitive-behavioral therapy, and group cognitive-behavioral therapy remain well-established; behavioral family-based treatment and motivational interviewing remain probably efficacious; drug counseling remains possibly efficacious; and an updated total of 5 multicomponent treatments combining more than 1 approach (3 of which include contingency management) are deemed well-established or probably efficacious. Treatment delivery issues associated with evidence-based approaches are then reviewed, focusing on client engagement, fidelity and mediator, and predictor and moderator effects. Finally, to help accelerate innovation in ASU treatment science and practice, the article outlines promising horizons in improving youth identification and access, specifying and implementing pragmatic treatment in community settings, and leveraging emerging lessons from implementation science.

A structural model of treatment program and individual counselor leadership in innovation transfer.

BACKGROUND: A number of program-level and counselor-level factors are known to impact the adoption of treatment innovations. While program leadership is considered a primary factor, the importance of leadership among clinical staff to innovation transfer is less known. Objectives included explore (1) the influence of two leadership roles, program director and individual counselor, on recent training activity and (2) the relationship of counselor attributes on training endorsement. METHODS: The sample included 301 clinical staff in 49 treatment programs. A structural equation model was evaluated for key hypothesized relationships between exogenous and endogenous variables related to the two leadership roles. RESULTS: The importance of organizational leadership, climate, and counselor attributes (particularly counseling innovation interest and influence) to recent training activity was supported. In a subset of 68 counselors who attended a developer-led training on a new intervention, it was found that training endorsement was higher among those with high innovation interest and influence. CONCLUSIONS: The findings suggest that each leadership level impacts the organization in different ways, yet both can promote or impede technology transfer.

Effectiveness of a theoretically-based judgment and decision making intervention for adolescents.

Although adolescents demonstrate capacity for rational decision making, their tendency to be impulsive, place emphasis on peers, and ignore potential consequences of their actions often translates into higher risk-taking including drug use, illegal activity, and physical harm. Problems with judgment and decision making contribute to risky behavior and are core issues for youth in treatment. Based on theoretical and empirical advances in cognitive science, the Treatment Readiness and Induction Program (TRIP) represents a curriculum-based decision making intervention that can be easily inserted into a variety of content-oriented modalities as well as administered as a separate therapeutic course. The current study examined the effectiveness of TRIP for promoting better judgment among 519 adolescents (37 % female; primarily Hispanic and Caucasian) in residential substance abuse treatment. Change over time in decision making and premeditation (i.e., thinking before acting) was compared among youth receiving standard operating practice (n = 281) versus those receiving standard practice plus TRIP (n = 238). Change in TRIP-specific content knowledge was examined among clients receiving TRIP. Premeditation improved among youth in both groups; TRIP clients showed greater improvement in decision making. TRIP clients also reported significant increases over time in self-awareness, positive-focused thinking (e.g., positive self-talk, goal setting), and recognition of the negative effects of drug use. While both genders showed significant improvement, males showed greater gains in metacognitive strategies (i.e., awareness of one's own cognitive process) and recognition of the negative effects of drug use. These results suggest that efforts to teach core thinking strategies and apply/practice them through independent intervention modules may benefit adolescents when used in conjunction with content-based programs designed to change problematic behaviors.

To Stay or Not To Stay: Adolescent Client, Parent, and Counselor Perspectives on Leaving Substance Abuse Treatment Early.

Increasing motivation and raising retention rates are considerable challenges for providers of adolescent substance abuse treatment. Research has shown that motivation for treatment, social influences (peers, family, counselors), and for some clients external pressure from the juvenile justice system, can serve as key factors in successful retention. To further understand influences on motivation and retention, focus groups were conducted in two residential treatment facilities. Adolescent clients, parents, and treatment staff were asked to describe their experiences with the treatment process focusing specifically on factors related to treatment attrition and retention. Qualitative data analysis revealed five themes affecting retention either positively or negatively. Themes included relationships (with family, peers, and counselors), responsibility (degree to which clients embrace jobs, roles, and rules), emotional regulation (ability to express feelings appropriately), thinking (identifying behavior patterns and recognizing consequences), and self-efficacy (feelings of empowerment). Implications for future research and for developing strategies aimed at increasing motivation and retention are discussed.

Screening and assessment tools for measuring adolescent client needs and functioning in substance abuse treatment.

The purpose of this study is to establish the psychometric properties of a noncommercial, publicly available, modular screening and assessment system for adolescents in substance abuse treatment. Data were collected in 2011-2012 from 1,189 adolescents admitted to eight residential treatment programs in urban and rural locations in the United States. Results from three sets of analyses documented the instruments to be reliable. Females reported more problems than males, and younger adolescents reported more problems than older youth. Implications and limitations are discussed, and suggestions for future research are provided.

Improving Adolescent Judgment and Decision Making.

Human judgment and decision making (JDM) has substantial room for improvement, especially among adolescents. Increased technological and social complexity "ups the ante" for developing impactful JDM interventions and aids. Current explanatory advances in this field emphasize dual processing models that incorporate both experiential and analytic processing systems. According to these models, judgment and decisions based on the experiential system are rapid and stem from automatic reference to previously stored episodes. Those based on the analytic system are viewed as slower and consciously developed. These models also hypothesize that metacognitive (self-monitoring) activities embedded in the analytic system influence how and when the two systems are used. What is not included in these models is the development of an intersection between the two systems. Because such an intersection is strongly suggested by memory and educational research as the basis of wisdom/expertise, the present paper describes an Integrated Judgment and Decision-Making Model (IJDM) that incorporates this component. Wisdom/expertise is hypothesized to contain a collection of schematic structures that can emerge from the accumulation of similar episodes or repeated analytic practice. As will be argued, in comparisons to dual system models, the addition of this component provides a broader basis for selecting and designing interventions to improve adolescent JDM. Its development also has implications for generally enhancing cognitive interventions by adopting principles from athletic training to create automated, expert behaviors.

Results of a national survey of substance use treatment services for youth under community supervision.

BACKGROUND: Despite the heightened risk for substance use (SU) among youth in the juvenile justice system, many do not receive the treatment that they need. OBJECTIVES: The purpose of this study is to examine the extent to which youth under community supervision by juvenile justice agencies receive community-based SU services and the factors associated with access to such services. METHODS: Data are from a nationally representative sample of Community Supervision (CS) agencies and their primary behavioral health (BH) partners. Surveys were completed by 192 CS and 271 BH agencies. RESULTS: SU services are more often available through BH than CS for all treatment modalities. EBPs are more likely to be used by BH than by CS. Co-location of services occurs most often in communities with fewer treatment options and is associated with higher interagency collaboration. Youth are more likely to receive services in communities with higher EBP use, which mediates the relationship between the availability of SU treatment modalities and the proportion of youth served. CONCLUSION: Findings identify opportunities to strengthen community systems and improve linkage to care.

Using structured implementation interventions to improve referral to substance use treatment among justice-involved youth: Findings from a multisite cluster randomized trial.

INTRODUCTION: Youth involved in the justice system have high rates of alcohol and other drug use, but limited treatment engagement. JJ-TRIALS tested implementation activities with community supervision (CS) and behavioral health (BH) agencies to improve screening, identification of substance use service need, referral, and treatment initiation and engagement, guided by the BH Services Cascade and EPIS frameworks. This paper summarizes intervention impacts on referrals to treatment among youth on CS. METHODS: This multisite cluster-randomized trial involved 18 matched pairs of sites in 36 counties in seven states randomly assigned to core or enhanced conditions after implementing the core intervention at all sites for six months. Enhanced sites received external facilitation for local change team activities to reduce unmet treatment needs; Core sites were encouraged to form interagency workgroups. The dependent variable was percentage referred to treatment among youth in need (N = 14,012). Two-level Bayesian regression assessed factors predicting referral across all sites and time periods. Generalized linear mixed models using logit transformation tested two hypotheses: (H1) referrals will increase from baseline to the experimental period, (H2) referral increases will be larger in enhanced sites than in core sites. RESULTS: Although the intervention significantly increased referral, condition did not significantly predict referral across all time periods. Youth who tested drug positive, had an alcohol/other drug-related or felony charge, were placed in secure detention or assigned more intensive supervision, or who were White were more likely to be referred. H1 (p < .05) and H2 (p < .0001) were both significant in the hypothesized direction. Interaction analyses comparing site pair differences showed that findings were not consistent across sites. CONCLUSIONS: The percentage of youth referred to treatment increased compared with baseline overall, and enhanced sites showed larger increases in referrals over time. However, variations in effects suggest that site-level differences were important. Researchers should carry out mixed methods studies to further understand reasons for the inconsistent findings within randomized site pairs, and how to further improve treatment referrals across CS and BH systems. Findings also highlight that even when CS agencies work collaboratively with BH providers to improve referrals, most justice-involved youth who need SU services are not referred.

The Missing Link(age): Multilevel Contributors to Service Uptake Failure Among Youths on Community Justice Supervision.

OBJECTIVES: Youths in the juvenile justice system often do not access needed behavioral health services. The behavioral health services cascade model was used to examine rates of substance use screening, identification of substance use treatment needs, and referral to and initiation of treatment among youths undergoing juvenile justice system intake and to identify when treatment access is most challenged. Characteristics associated with identification of behavioral health needs and linkage to community services were also examined. METHODS: Data were drawn from administrative records of 33 community justice agencies in seven states participating in Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System, funded by the National Institute on Drug Abuse (N=8,307 youths). Contributions of youth, staff, agency, and county characteristics to identification of behavioral health needs and linkage to community services were examined. RESULTS: More than 70% (5,942 of 8,307) of youths were screened for substance use problems, and more than half needed treatment. Among those in need, only about one-fifth were referred to treatment, and among those referred, 67.5% initiated treatment. Overall, <10% of youths with identified needs initiated services. Multivariable multilevel regression analyses revealed several contributors to service-related outcomes, with youths' level of supervision being among the strongest predictors of treatment referral. CONCLUSIONS: Community justice agencies appear to follow an approach that focuses identification and linkage practices on concerns other than youths' behavioral health needs, although such needs contribute to reoffending. Local agencies should coordinate efforts to support interagency communication in the referral and cross-system linkage process.

The development and validation of a transformational leadership survey for substance use treatment programs.

Directors in substance use treatment programs are increasingly required to respond to external economic and socio-political pressures. Leadership practices that promote innovation can help offset these challenges. Using focus groups, factor analysis, and validation instruments, the current study developed and established psychometrics for the Survey of Transformational Leadership. In 2008, clinical directors were evaluated on leadership practices by 214 counselors within 57 programs in four U.S. regions. Nine themes emerged: integrity, sensible risk, demonstrates innovation, encourages innovation, inspirational motivation, supports others, develops others, delegates tasks, and expects excellence. Study implications, limitations, and suggested future directions are discussed.

HIV/STI Service Delivery Within Juvenile Community Supervision Agencies: A National Survey of Practices and Approaches to Moving High-Risk Youth Through the HIV Care Cascade.

Justice-involved youth (JIY) are at considerable risk for human immunodeficiency virus (HIV), but are disconnected from treatment and prevention. Juvenile justice agencies providing community supervision (CS) are well positioned to provide HIV prevention, testing, and prompt referral to treatment for JIY. However, we lack an understanding of juvenile CS agency responses to HIV/sexually transmitted infection (STI) needs among JIY. We conducted a nationwide systematic assessment of how juvenile CS agencies identify, refer, and move youth through the HIV care cascade using a nationally representative sample of 195 juvenile CS agencies across 20 states. Two-thirds of CS agencies did not offer any HIV-/STI-related services, and 82% reported no collaboration with health agencies. Screening or referral for HIV risk behaviors was reported by 32% of the CS agencies and 12% for any intervention or prevention for HIV/STI risk behaviors. Between 21% and 30% of agencies were unaware of the location of local HIV/STI services. HIV/STI prevention training was not a priority for directors and was ranked second to last out of 16 training topics. Agencies where staff expressed need for HIV risk training and where specific court programming was available were more likely to provide or refer for HIV/STI screening and/or testing. Agencies were more likely to provide or refer for services if they provided pre-trial/pre-adjudication supervision, parole, or court programming. Considering the low provision of HIV/STI-related services and limited collaboration between health and justice agencies, interventions that promote cross-system collaboration designed to minimize barriers and facilitate identification, referral, and linkage to HIV services for JIY are necessary.

Juvenile justice staff endorsement of HIV/STI prevention, testing, and treatment linkage.

BACKGROUND: While involvement in the legal system offers an opportunity to educate, screen, and treat high-risk youth, research shows that staff attitudes toward these practices can serve as barriers to implementation. The current study investigates the degree to which JJ staff endorse HIV prevention, testing, and treatment linkage practices with youth under community supervision and examines differences between individuals who supervise youth (e.g., juvenile probation officer) and those working in non-supervisory roles (e.g., case manager, assessment specialist). METHODS: Juvenile justice staff consenting to participation in JJ-TRIALS completed an initial staff survey (N = 501). Survey items measured perceived importance of HIV/STI prevention (4 items); perceived importance of HIV/STI testing (7 items); and perceived importance of HIV/STI treatment linkage (8 items). RESULTS: Confirmatory Factor Analysis (CFA) was computed (SAS CALIS procedure) for each of the three domains. Findings suggest that while staff recognize that youth are at risk for HIV/STIs and require provision of HIV/STI prevention and treatment linkage, attitudes concerning the importance of procuring or providing testing services for youth is substantially lower. Furthermore, analytic models comparing staff with and without supervision responsibilities (computed using SAS PROC MIXED) indicated that attitudes differed by site and staff responsible for supervision rated HIV treatment linkage practices as less important compared to non-supervising staff. CONCLUSIONS: Establishing partnerships with health agencies equipped with resources and skillsets to provide HIV/STI testing and related services may be an effective model to promote greater awareness and use of best practices among JJ staff and more effectively address the unmet needs of this high-risk population of youth.

Organizational Context and Individual Adaptability in Promoting Perceived Importance and Use of Best Practices for Substance Use.

This study examines associations among organizational context, staff attributes, perceived importance, and use of best practices among staff in community-based, juvenile justice (JJ) agencies. As part of the National Institute on Drug Abuse's Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) study, 492 staff from 36 JJ agencies were surveyed about the perceived importance and use of best practices within their organization in five substance use practice domains: screening, assessment, standard referral, active referral, and treatment support. Structural equation models indicated that supervisory encouragement and organizational innovation/flexibility were associated with greater individual adaptability. Adaptability (willingness to try new ideas, use new procedures, adjust quickly to change), was positively correlated with importance ratings. Importance ratings were positively associated with reported use of best practices. Organizational climates that support innovation likely affect use of practices through staff attributes and perceptions of the importance of such services.

Program structure and counselor-client contact in outpatient substance abuse treatment.

OBJECTIVES: To examine organizational structural attributes associated with counselor-client contact. DATA SOURCES: Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. STUDY DESIGN: The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. DATA COLLECTION: Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. PRIMARY FINDINGS: Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. CONCLUSIONS: Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.