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.

HIV Stigma in Prisons and Jails: Results from a Staff Survey.

With numerous HIV service gaps in prisons and jails, there has been little research on HIV stigma attitudes among correctional staff. Such attitudes may undermine HIV services for inmates at risk of or infected with HIV. This HIV stigma attitudes survey among 218 correctional staff in 32 US facilities (1) provides an overview of staff's stigma attitudes, (2) reports psychometric analyses of domains in Earnshaw and Chaudoir's HIV Stigma Framework (HSF), and (3) explores differences in stigma attitudes among different staff types. Overall, correctional and medical staff expressed non stigmatizing attitudes toward people living with HIV/AIDS, but perceived that stigma and discrimination exist in others. Factor analyses revealed a three factor structure capturing two mechanisms of the HSF (prejudice, discrimination). Few factor score differences were found by staff type or setting. Implications for correctional HIV services and future research on HIV stigma attitudes are discussed.

The Validity of Truant Youths' Marijuana Use and Its Impact on Alcohol Use and Sexual Risk Taking.

Few studies investigating the validity of marijuana use have used samples of truant youth. In the current study, self-reports of marijuana use are compared with urine test results for marijuana to identify marijuana underreporting among adolescents participating in a longitudinal Brief Intervention for drug-involved truant youth. It was hypothesized that marijuana underreporting would be associated with alcohol underreporting and engaging in sexual risk behaviors. The results indicated marijuana underreporting was significantly associated with self-denial of alcohol use, but not associated with sexual risk behavior. Also, there was an age effect in marijuana use underreporting such that younger truant youth were more likely to underreport marijuana use, compared to older truant youth. Implications for policy and future research are discussed.

Efficacy of a process improvement intervention on delivery of HIV services to offenders: a multisite trial.

OBJECTIVES: We tested a modified Network for the Improvement of Addiction Treatment (NIATx) process improvement model to implement improved HIV services (prevention, testing, and linkage to treatment) for offenders under correctional supervision. METHODS: As part of the Criminal Justice Drug Abuse Treatment Studies, Phase 2, the HIV Services and Treatment Implementation in Corrections study conducted 14 cluster-randomized trials in 2011 to 2013 at 9 US sites, where one correctional facility received training in HIV services and coaching in a modified NIATx model and the other received only HIV training. The outcome measure was the odds of successful delivery of an HIV service. RESULTS: The results were significant at the .05 level, and the point estimate for the odds ratio was 2.14. Although overall the results were heterogeneous, the experiments that focused on implementing HIV prevention interventions had a 95% confidence interval that exceeded the no-difference point. CONCLUSIONS: Our results demonstrate that a modified NIATx process improvement model can effectively implement improved rates of delivery of some types of HIV services in correctional environments.

Brief Intervention for Truant Youth Sexual Risk Behavior and Alcohol Use: A Parallel Process Growth Model Analysis.

Truant youths represent a challenging, yet very promising group of at-risk youth to study. In addition to problems in school, they frequently experience troubled family situations, emotional/ psychological problems, involvement in substance use, and delinquency. Given the problems often experienced by truant youth, it is likely they are engaging in alcohol use and sexual risk behavior at a higher rate, than the general youth population. Identification of these youths' problems and early placement into effective intervention services would benefit them, their families, and society. The current study presents interim findings from an ongoing, NIDA-funded experimental, Brief Intervention (BI) study involving truant youths and their parent/guardians. Baseline, 3-month, 6-month, and 12-month follow up data were analyzed to determine whether alcohol use and sexual risk behaviors were longitudinally related, examine the effects of the intervention on longitudinal alcohol use and sexual risk behaviors, identify latent subgroups of youths in the data for alcohol use and sexual risk behaviors, and determine whether the intervention influenced these subgroups. Results indicated alcohol use and sexual risk were longitudinally related. Subgroups of youth were also identified based on alcohol use and sexual risk behavior levels and trends. Further, limited treatment effects were observed for alcohol use. Implications of the results for future research and service delivery are considered.

Brief Intervention for Truant Youth Sexual Risk Behavior and Marijuana Use.

Substance use and sexual risk behaviors are common among adolescents. Although attention has focused primarily on alcohol use, less is known about the relationship between marijuana use and sexual risk behavior among high-risk youth. Since truant youth often experience problems in school, troubled family situations, and other psychosocial problems, they represent an important group of high-risk youth to study. Previous research suggests that truant youth are at considerable risk of continuing their troubled behavior in school and entering the juvenile justice system. It is also likely that truant youth are involved in marijuana use and sexual risk behavior at a higher rate, than the general youth population. Involving them in effective intervention services could reduce these risk behaviors. The current study presents interim findings from a NIDA-funded experimental, brief intervention (BI) study involving truant youths and their parents/guardians. Longitudinal data were analyzed to study: (1) the relationships between the youths' marijuana use and engaging in sexual risk behavior over time, and (2) the effects of a substance use BI on their marijuana use and sexual risk behavior. Analyses examined a growth model for parallel processes in marijuana use and sexual risk behavior, and an assessment of the effect of the intervention on linear and quadratic trends, and on subgroups of youth differing in their sexual risk behavior and marijuana use. Implications of the results for future research and service delivery are considered.

Impact of Brief Intervention Services on Drug Using Truant Youth Arrest Charges over Time.

School truancy is a serious concern in the U.S., with far-reaching negative consequences. Truancy has been positively associated with substance use and delinquent behavior; however, research is limited. Consequently, the Truancy Brief Intervention Project was established to treat and prevent substance use and other risky behaviors among truants. This article examines whether the Brief Intervention program is more effective in preventing future delinquency over a 12-month follow-up period, than the standard truancy program. Results indicate the Brief Intervention was marginally significant in effecting future delinquency among truants, compared to the standard truancy program. Future implications of this study are discussed.

Feasibility of a computerized intervention for offenders with substance use disorders: a research note.

OBJECTIVES: Despite evidence that treatment is effective in reducing recidivism among inmates with substance use problems, scarce resources mean that few of those in need of treatment actually receive it. Computerized substance abuse interventions could be used to expand access to treatment in prisons without placing an undue burden on resources. The major aim of the study was to compare treatment conditions in terms of their service utilization, skills acquisition, and treatment satisfaction. METHODS: The study recruited men and women with substance use disorders from 10 prisons in 4 states. In an open label clinical trial, 494 subjects were randomly assigned either to the Experimental condition, a computerized drug treatment intervention, the Therapeutic Education System (TES; n = 249), or to the Control condition, Standard Care (n = 245). Chi-square tests compared groups on categorical variables and independent samples t tests were used for interval level continuous variables. RESULTS: Initial evidence demonstrated: (1) comparable group rates of session attendance and high rates of TES module completion for experimental subjects; (2) comparable group gains in the development of coping skills; and (3) a more favorable view of TES than of Standard Care. CONCLUSIONS: Collectively, these results show that a computerized intervention, such as TES, can be implemented successfully in prison. Given the barriers to the delivery of substance abuse treatment typically encountered in correctional settings, computerized interventions have the potential to fill a significant treatment gap and are particularly well suited to inmates with mild to moderate substance use disorders who often are not treated.

The impact of co-occurring mental health problems on referral to and initiation of treatment among youth under probation supervision: Findings from a cluster randomized trial.

INTRODUCTION: Many youth under community supervision have substance use and co-occurring mental health issues. Yet, access to treatment is limited, and many programs cannot address co-occurring disorders. This study examines how co-occurring symptoms among youth on probation affect referral to and initiation of treatment. We hypothesize that both referral and initiation rates will be lower for youth with any co-occurring indicators. METHODS: This study collected administrative data from 14 sites in three states between March 2014 and November 2017 using JJ-TRIALS, a cluster randomized trial. Among 8552 youth in need of treatment (screened as having a substance use problem, drug possession arrest, positive drug test, etc.), 2069 received a referral to treatment and 1630 initiated treatment among those referred. A co-occurring indicator (n = 2828) was based on symptoms of an internalizing and/or externalizing issue. Descriptive analyses compared referral and initiation by behavioral health status. Two-level mixed effects logistic regression models estimated effects of site-level variables. RESULTS: Among youth in need with co-occurring internal, external, or both indicators, only 16 %, 18 %, and 20 % were referred to treatment and of those referred, 63 %, 69 %, and 57 % initiated treatment, respectively. Comparatively, 27 % and 83 % of youth with a substance use only indicator were referred and initiated treatment respectively. Multi-level multivariate models found that, contrary to our hypothesis, co-occurring-both (p = 0.00, OR 1.44) and co-occurring-internal indicators (p = 0.06, OR 1.25) predicted higher referral but there were no differences in initiation rates. However, there was substantial site-level variation. CONCLUSIONS: Youth on probation in need of substance use treatment with co-occurring issues have low referral rates. Behavioral health status may influence youth referral to treatment depending on where a youth is located. Depending on the site, there may be a lack of community programs that can adequately treat youth with co-occurring issues and reduce unmet service needs.

Conditions of successful treatment referral practices with justice-involved youth: Qualitative insights from probation and service provider staff involved in JJ-TRIALS.

INTRODUCTION: Compared to the general U.S. adolescent population, young people involved in the juvenile justice system are at greater risk of experiencing substance use (SU) issues. There are critical opportunities across the juvenile justice continuum, at points of interface with community-based treatment services, to screen and assess for SU issues, identify unmet treatment needs, and refer those in need to treatment. The treatment referral process is, however, complex, and contingent on a seamless nexus between juvenile justice operations and the wider treatment provider landscape. Given the lack of successful SU referrals among justice-involved youth and the variable referral rates across jurisdictions, this study's aim is to provide a qualitative, explanatory understanding of the conditions that together contribute to successful referring practices. METHODS: The study is based on an analysis of a qualitative dataset comprising focus group data with probation and community-based behavioral health treatment staff working in 31 sites in 6 different states as part of the clustered randomized trial of an organizational change intervention known as JJ-TRIALS (Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System). The data contain respondents' narratives on the achievements, successes, and challenges with implementing the intervention. The data were analyzed through a combination of strategies to identify the conditions that both facilitate and impede referral processes between probation offices and community-based SU treatment providers. RESULTS: Participants across sites discussed the positive impacts that the JJ-TRIALS intervention had on their improved ability to communicate, collaborate, and collect data. From the interviews, seven main conditions were observed to contribute to successful SU treatment referral practices: (1) communication (inter-organizational); (2) collaboration; (3) data-driven practices; (4) family engagement; (5) institutionalized policy and referral documentation; (6) efficient referral policies and procedures; and (7) suitable and accessible system of treatment providers. CONCLUSION: Findings highlight the value of a holistic understanding of successful treatment referrals for justice-involved youth and help inform research and practice efforts to identify and measure the many dimensions of referral-making at the interface of juvenile probation and behavioral health services.

Linkage facilitation for opioid use disorder in criminal legal system contexts: a primer for researchers, clinicians, and legal practitioners.

At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS.

Treating substance use disorders in the criminal justice system.

The large number of individuals with substance use disorders involved in the nation's criminal justice system (CJS) represents a unique opportunity, as well as challenges, in addressing the dual concerns of public safety and public health. Unfortunately, a low proportion of those who could benefit from treatment actually receive it while involved in the CJS. This article presents a review of recent research on the effectiveness of major substance abuse treatment interventions used at different possible linkage points during criminal justice case processing, including diversion, jail, prison, and community supervision. This is followed by a discussion of key research and practice issues, including low rates of treatment access and under-utilization of medication-assisted treatment. Concluding comments discuss principles of effective treatment for offenders and identify key gaps in research and practice that need to be addressed to improve and expand provision of effective treatment for offenders.

The Mental Health, Substance Use, and Delinquency among Truant Youths in a Brief Intervention Project: A Longitudinal Study.

The relationship between substance use, mental health disorders, and delinquency among youth is well documented. What has received far less attention from researchers is the relationship between these issues among truant youth, in spite of studies that document truants are a population at-risk for negative outcomes. The present study bridges this gap by (1) examining psychosocial functioning and delinquency among truants, and (2) assessing the efficacy of a Brief Intervention (BI) in reducing delinquent behavior over time. To meet these objectives, data were collected from 183 truant youth enrolled in an ongoing NIDA-funded BI project. Informed by a developmental damage perspective, a structural equation model was formulated and estimated. Interim results provide overall support for the model, and suggest the BI may be a promising, innovative intervention for truant youth. Service delivery implications and directions for future analyses are discussed.

PREDICTING RECIDIVISM FOR RELEASED STATE PRISON OFFENDERS: Examining the Influence of Individual and Neighborhood Characteristics and Spatial Contagion on the Likelihood of Reincarceration.

We examined the influence of individual and neighborhood characteristics and spatial contagion in predicting reincarceration on a sample of 5,354 released Pennsylvania state prisoners. Independent variables included demographic characteristics, offense type, drug involvement, various neighborhood variables (e.g., concentrated disadvantage, residential mobility), and spatial contagion (i.e., proximity to others who become reincarcerated). Using geographic information systems (GIS) and logistic regression modeling, our results showed that the likelihood of reincarceration was increased with male gender, drug involvement, offense type, and living in areas with high rates of recidivism. Older offenders and those convicted of violent or drug offenses were less likely to be reincarcerated. For violent offenders, drug involvement, age, and spatial contagion were particular risk factors for reincarceration. None of the neighborhood environment variables were associated with increased risk of reincarceration. Reentry programs need to particularly address substance abuse issues of ex-offenders as well as take into consideration their residential locations.

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.

Benefits and costs of substance abuse treatment programs for state prison inmates: results from a lifetime simulation model.

Reflecting drug use patterns and criminal justice policies throughout the 1990s and 2000s, prisons hold a disproportionate number of society's drug abusers. Approximately 50% of state prisoners meet the criteria for a diagnosis of drug abuse or dependence, but only 10% receive medically based drug treatment. Because of the link between substance abuse and crime, treating substance abusing and dependent state prisoners while incarcerated has the potential to yield substantial economic benefits. In this paper, we simulate the lifetime costs and benefits of improving prison-based substance abuse treatment and post-release aftercare for a cohort of state prisoners. Our model captures the dynamics of substance abuse as a chronic disease; estimates the benefits of substance abuse treatment over individuals' lifetimes; and tracks the costs of crime and criminal justice costs related to policing, adjudication, and incarceration. We estimate net societal benefits and cost savings to the criminal justice system of the current treatment system and five policy scenarios. We find that four of the five policy scenarios provide positive net societal benefits and cost savings to the criminal justice system relative to the current treatment system. Our study demonstrates the societal gains to improving the drug treatment system for state prisoners.

Emotional/psychological and related problems among truant youths: An exploratory latent class analysis.

Latent class analysis was conducted on the psychosocial problems experienced by truant youths. Data were obtained from baseline interviews completed on 131 youths and their parents/guardians involved in a NIDA-funded, Brief Intervention Project. Results identified two classes of youths: Class 1(n=94): youths with low levels of delinquency, mental health and substance abuse issues, Class 2(n=37): youths with high levels of these problems. Comparison of these two classes on their urine analysis test results and parent/guardian reports of traumatic events found significant (p<.05) differences between them that were consistent with their problem group classification. Our results have important implications for research and practice.

Stress, Mental Health and Substance Abuse Problems In a Sample of Diversion Program Youth: An Exploratory Latent Class Analysis.

Reflective of interest in mental health and substance abuse issues among youths involved with the justice system, we performed a latent class analysis on baseline information collected on 100 youths involved in two diversion programs. Results identified two groups of youths: Group 1: a majority of the youths, who had high levels of delinquency, mental health and substance abuse issues, Group 2: youths with low levels of these problems. Comparison of these two groups on a variety of psychosocial measures and parent/guardian reports found differences between them that were consistent with their problem group classification. Follow-up analysis confirmed problem behavior that was consistent with the youths' latent class placement. Implications of the findings for research and practice will be presented.