30 years of youth system of care lessons learned - a qualitative study of Hawai'i's partnership with the Substance Abuse and Mental Health Services Administration.

BACKGROUND: The Hawai'i State Department of Health, Child and Adolescent Mental Health Division (CAMHD) has maintained a longstanding partnership with Substance Abuse and Mental Health Services Administration (SAMHSA) to enhance capacity and quality of community-based mental health services. The current study explored CAMHD's history of SAMHSA system of care (SOC) awards and identified common themes, lessons learned, and recommendations for future funding. METHODS: Employing a two-phase qualitative approach, the study first conducted content analysis on seven final project reports, identifying themes and lessons learned based on SOC values and principles. Subsequently, interviews were conducted with 11 system leaders in grant projects and SOC award projects within the state. All data from project reports and interview transcripts were independently coded and analyzed using rapid qualitative analysis techniques. RESULTS: Content validation and interview coding unveiled two content themes, interagency collaboration and youth and family voice, as areas that required long-term and consistent efforts across multiple projects. In addition, two general process themes, connection and continuity, emerged as essential approaches to system improvement work. The first emphasizes the importance of fostering connections in family, community, and culture, as well as within workforce members and child-serving agencies. The second highlights the importance of nurturing continuity throughout the system, from interagency collaboration to individual treatment. CONCLUSIONS: The study provides deeper understanding of system of care evaluations, offering guidance to enhance and innovate youth mental health systems. The findings suggest that aligning state policies with federal guidelines and implementing longer funding mechanisms may alleviate administrative burdens.

A health crisis within a health crisis: Opioid access in the COVID-19 pandemic.

The novel coronavirus has thrown large sections of our healthcare system into disarray, with providers overburdened by record breaking number of hospitalizations and deaths. The U.S., in particular, has remained the nation with one of the fastest growing case counts in the world. As a consequence, many other critical healthcare needs have not received the necessary resources or consideration. This commentary draws attention to substance use and opioid access during the ongoing crisis, given the potential for breakdowns in treatment access for addiction, the growing concern of mental health comorbidities, and the lack of access for those who require opioids for adequate pain management. Further, the commentary will offer policy and practice recommendations that may be implemented to provide more equitable distribution of care.

Explication and Definition of Mental Health Recovery: A Systematic Review.

This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/person centered, empowerment, purpose, and hope.

Identifying and Reducing Disparities in Mental Health Outcomes Among American Indians and Alaskan Natives Using Public Health, Mental Healthcare and Legal Perspectives.

The purpose of this paper was to investigate disparities in mental healthcare delivery in American Indian/Alaska Native populations from three perspectives: public health, legal policy and mental healthcare and provide evidence-based recommendations toward reducing those disparities. Data on mental health funding to tribes were obtained from the Substance Abuse and Mental Health Services Administration. As a result of analysis of these data, vital statistics and current literature, we propose three recommendations to reduce mental health disparities. First, where possible, increase mental health funding opportunities for federally-recognized tribes. Second, model funding practices on principles of tribal self-determination. Finally, support diverse interventions that are culturally-based and culturally-appropriate.

Ethical Challenges Inherent in the Evaluation of an American Indian/Alaskan Native Circles of Care Project.

This article provides first-person accounts of ethical issues inherent in an evaluation of the Native American Indian Center of Central Ohio (NAICCO) Circles of Care project. Circles of Care is a three-year, infrastructure development program funded through the Substance Abuse and Mental Health Services Administration (SAMHSA) which is part of the federal Department of Health and Human Services (DHHS). The grant program is for American Indian and Alaskan Native (AI/AN) tribes and urban Indian communities and includes a strong emphasis on community engagement and community ownership. The Native American Indian Center of Central Ohio received a Circles of Care grant in the fifth cohort of the program. The first author (Project Evaluator) presents views that typically represent a western approach to evaluation, while the second author (Project Director) presents a Native perspective. Ethical issues are defined as well as the authors' efforts to address these concerns.

A brief report on Hispanic youth marijuana use: Trends in substance abuse treatment admissions in the United States.

Increases in Hispanic youth admissions to substance abuse treatment programs for marijuana use are a growing public health concern. In this study, we investigated trends in Hispanic youth from 1995 to 2012 utilizing the Treatment Episode Data Set-Admissions of the Substance Abuse Mental Health Services Administration. Hispanic youth marijuana admissions are associated with youth 15-17 years old, in high school, and living in a dependent situation. Notably, female admissions increased at greater rates than males. Results also point to decreasing tolerance of minor marijuana use by schools and community agencies. Findings highlight the need for targeted, culturally specific, and cost-effective treatment and prevention efforts.

The New Substance Abuse and Mental Health Services Administration Oral Fluid Cutoffs for Cocaine and Heroin-Related Analytes Applied to an Addiction Medicine Setting: Important, Unanticipated Findings with LC-MS/MS.

BACKGROUND: We implemented oral fluid (OF) as an alternative specimen type to urine for detection of cocaine (COC) and opiate abuse in outpatient addiction medicine clinics. METHODS: We implemented a 2-µg/L limit of quantification OF LC-MS/MS assay and compiled and reviewed all findings from a 22-month collection period for COC, benzoylecgonine (BZE), codeine (COD), 6-acetylmorphine (MAM), and morphine (MOR). We also compared the results of our clinical samples at different OF cutoffs and analytes specified in the new 2015 SAMHSA OF guidelines. RESULTS: Of 3608 OF samples, COC and BZE were positive in 593 and 508, respectively. COC or BZE was positive in 662 samples. Importantly and unexpectedly, 154 samples were COC positive and BZE negative, with 125 having COC 2.0-7.9 µg/L. A simulation with the new guideline cutoffs confirmed 65% (430 of 662) of all COC- or BZE-positive data set samples. Similarly, the new guidelines confirmed 44% (263 of 603) of data set samples positive for MOR or COD. Simulation found that the new, lower MAM guideline cutoffs detected 89% of the 382 MAM-positive samples in the data set, 104 of which the new guidelines had identified as negative for MOR and COD. CONCLUSIONS: COC (not BZE) is the dominant low-concentration OF analyte in an addiction medicine setting. This information will aid OF test interpretation. It also illustrates the importance of the 2015 guideline's new immunoassay cross-reactivity requirements and the likely improvement in detection of heroin use stemming from the new, lower MAM cutoffs.

Converging Patterns of Alcohol Use and Related Outcomes Among Females and Males in the United States, 2002 to 2012.

BACKGROUND: Females in the United States consume less alcohol and cause and experience fewer alcohol-related harms than males. However, recent research suggests such gaps might be narrowing. The purpose of this study was to explore changes in alcohol use and associated outcomes among females and males in the United States between 2002 and 2012. METHODS: Data from the National Survey on Drug Use and Health were used to assess the prevalence and trends for females and males aged 12+ in lifetime abstinence, age of onset, current drinking, binge drinking, drinking and driving, reaching DSM-IV criteria for an alcohol use disorder, combining alcohol with other drugs such as marijuana, and other variables. Of particular interest was whether differences between females and males narrowed during the decade under study. RESULTS: Differences in the drinking patterns of females and males aged 12+ narrowed between 2002 and 2012 for current drinking, number of drinking days per month, past year DSM-IV alcohol abuse, and past-year driving under the influence of alcohol. In addition, convergence was noted in 1 or more age subgroups for the prevalence of binge drinking and DSM-IV alcohol dependence and mean age at drinking onset. Divergence in drinking habits did not occur for any measure in any age subgroups with the exception of a greater increase in the prevalence of combining alcohol with marijuana among young adult male drinkers than female drinkers aged 18 to 25. CONCLUSIONS: Between 2002 and 2012, differences in alcohol consumption and related outcomes narrowed for females and males. Reasons for converging patterns of alcohol use are unclear and do not appear to be easily explainable by recent trends in employment status, pregnancy status, or marital status. More research is needed to identify the psychosocial and environmental contributors to these changes and to assess implications for prevention and treatment efforts.

Addiction treatment staff perceptions of training as a facilitator or barrier to implementing evidence-based practices: a national qualitative research study.

BACKGROUND: This qualitative effort examines training-related facilitators and barriers to implementing evidence-based practices (EBPs) in 285 community-based addiction treatment organizations (CBOs) nationwide that were funded by the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment (SAMHSA/CSAT) to implement EBPs. METHODS: Using qualitative interviews, the authors explored staff (N = 514) descriptions of training as a facilitator or barrier to implementation. Training-related factors were described 663 times as facilitators (by 440 staff) and 233 times as barriers (by 170 staff). Responses were coded using content analysis. RESULTS: Specific characteristics of the training received, such as access to expert knowledge and quality, as well as ongoing training were described as central facilitating factors to EBP implementation. Key reasons training was perceived as a barrier included the amount of training; the training did not fit current staff and/or organizational needs; the training for some EBPs was perceived to be too demanding; and the difficulty accessing training. CONCLUSIONS: Since government funders of addiction treatments require that CBOs implement EBPs and they provide training resources, the quality, flexibility, and accessibility of the available training needs to be promoted throughout the addiction treatment network. Only 17% of CBOs reported that they used the SAMHSA-funded ATTC (Addiction Technology Transfer Center) training centers and 42% used SAMHSA technical assistance. Hence, federally funded resources for training were not always used.

Substance abuse and mental health visits among adolescents presenting to US emergency departments.

OBJECTIVES: The objectives of the study were to identify factors associated with adolescent emergency department (ED) visits for substance abuse, including those complicated by mental health (dual diagnosis), and to analyze their effect on ED length of stay (LOS) and disposition. METHODS: We performed a secondary analysis of ED visits by adolescents (age, 11-24) using the National Hospital Ambulatory Medical Care Survey (1997-2010) to identify visits for mental health, substance use, and dual diagnosis. Univariate and multivariate statistics were used to analyze demographic and visit-level factors, factors associated with substance use and dual diagnosis visits, as well as the effects of substance use and mental health conditions on ED LOS and disposition. RESULTS: Substance use and mental health accounted for 2.1% and 4.3% of all adolescent visits, respectively, with 20.9% (95% confidence interval [CI], 18.3%-23.5%) of substance abuse visits complicated by mental health. The factors significantly associated with substance use include the following: male sex, urban location, West region, ambulance arrival, night and weekend shift, anxiety disorders, mood disorders, and psychotic disorders. Additional LOS was 89.77 minutes for mental health, 71.33 minutes for substance use, and 139.97 minutes for dual diagnosis visits, as compared with visits where these conditions were not present. Both mental health and substance use were associated with admission/transfer as compared with other dispositions as follows: mental health odds ratio (OR), 5.93 (95% CI, 5.14-6.84); illicit drug use OR, 3.56 (95% CI 2.72-4.64); and dual diagnosis OR, 6.86 (95% CI, 4.67-10.09). CONCLUSIONS: Substance abuse and dual diagnosis are common among adolescent ED visits and are strongly associated with increased use of prehospital resources, ED LOS, and need for hospitalization.

Sustainability of State-Level Substance Abuse Prevention Infrastructure After the Completion of the SPF SIG.

Recent national substance abuse prevention efforts that have been disseminated at the state level have provided fertile ground for addressing the dearth of systematic research on state-level substance abuse prevention infrastructure. The Strategic Prevention Framework State Incentive Grant Program (SPF SIG), a national public health initiative sponsored by the US Substance Abuse and Mental Health Services Administration and its Center for Substance Abuse Prevention, is one such effort, providing an opportunity to examine state-level substance abuse prevention infrastructure across the country. The aims of the SPF SIG initiative include reducing substance abuse and its related problems, as well as enhancing state and local prevention infrastructure and capacity. In this article, we describe the status of state-level substance abuse prevention infrastructure and capacity 1 year after the first 26 funded states ended their projects, based on follow-up interviews with state prevention decision-makers. We found that, in five of the six prevention domains we measured, prevention infrastructure capacity increased during the 12-month period after the grants ended. The evidence for further SPF capacity development even after the conclusion of the grants suggests that states recognized the benefits of using the SPF and took deliberate steps to sustain and enhance the integration of this framework into their state prevention systems. In addition, the findings suggest that state agencies and organizations can benefit from time-limited resources aimed at increasing their capacity and that such efforts can have a lasting impact on measures of state prevention system capacity.

From the sidelines to the frontline: how the Substance Abuse and Mental Health Services Administration embraced smoking cessation.

Smoking is a major contributor to premature mortality among people with mental illness and substance abuse. Historically, the Substance Abuse and Mental Health Services Administration (SAMHSA) did not include smoking cessation in its mission. We describe the development of a unique partnership between SAMHSA and the University of California, San Francisco's Smoking Cessation Leadership Center. Starting with an educational summit in Virginia in 2007, it progressed to a jointly sponsored "100 Pioneers for Smoking Cessation" campaign that provided grants and technical assistance to organizations promoting cessation. By 2013, the partnership established 7 "Leadership Academies," state-level multidisciplinary collaboratives of organizations focused on cessation. This academic-public partnership increased tobacco quit attempts, improved collaboration across multiple agencies, and raised awareness about tobacco use in vulnerable populations.

The Affordable Care Act: implementation and implications for addiction specialty care.

Converging in 2015 are the implementation of key pieces of the Affordable Care Act (ACA) and the implementation of the International Classification of Diseases, 10th edition (ICD-10). The implications for addiction care in the United States are substantial. This editorial discusses opportunities and challenges presented by these major changes to medicine and addiction specialty care.

Organizational Network Analysis of SAMHSA's Technology Transfer Center (TTC) Network.

Technology transfer centers (TTCs) facilitate the movement of evidence-based practices in behavioral healthcare from theory to practice. One of the largest such networks is the Substance Abuse and Mental Health Services Administration's (SAMHSA) TTC Network. This brief report shares findings from an organizational network analysis (ONA) of the network conducted as part of an external evaluation. For non-supervisory TTCs (n = 36) across three focus areas (addiction, prevention, and mental health), the authors computed network density, harmonic closeness, and non-null dyadic reciprocity for five types of interactions (e.g., "collaborated in workgroups"), then, for each interaction type, used Welch's T-test to compare mean harmonic closeness of standalone TTC grantees versus multiple-TTC grantees. ONA identified potentially isolated regional TTCs as well as mismatches between some centers' desired scope and their network centrality and enabled investigation of broader questions around behavioral health support systems. The approach appears useful for evaluating TTCs and similar support networks.

Commentary on the Revision of SAMHSA's National Outcome Measures (NOMs) for Discretionary Programs.

Data collection is an integral part of government agencies like the Substance Abuse and Mental Health Administration (SAMHSA), for reporting program outcomes and accountability. SAMHSA-funded community behavioral health programs have been evaluated by the National Outcome Measures (NOMs) since 2007. NOMs collects data on important aspects of client health including but not limited to mental health symptoms, functioning, and social connectedness through interviews with clients. Since its inception, NOMs has gone through a number of revisions. The most recent revision in 2021 has significant implications for program evaluation and research. This commentary provides an overview of the history of the NOMs followed by a review and critique of the recent changes with a particular attention to revisions in how responses are recorded. Implications of the NOMs are discussed with respect to its utility in evaluation, practice, and research.

Continuous Quality Improvement in the Substance Abuse and Mental Health Services Administration's Technology Transfer Center Network: A Process Evaluation.

In healthcare and related fields, there is often a gap between research and practice. Scholars have developed frameworks to support dissemination and implementation of best practices, such as the Interactive Systems Framework for Dissemination and Implementation, which shows how scientific innovations are conveyed to practitioners through tools, training, and technical assistance (TA). Underpinning those aspects of the model are evaluation and continuous quality improvement (CQI). However, a recent meta-analysis suggests that the approaches to and outcomes from CQI in healthcare vary considerably, and that more evaluative work is needed. Therefore, this paper describes an assessment of CQI processes within the Substance Abuse and Mental Health Services Administration's (SAMHSA) Technology Transfer Center (TTC) Network, a large TA/TTC system in the United States comprised of 39 distinct centers. We conducted key informant interviews (n = 71 representing 28 centers in the Network) and three surveys (100% center response rates) focused on CQI, time/effort allocation, and Government Performance and Results Act (GPRA) measures. We used data from each of these study components to provide a robust picture of CQI within a TA/TTC system, identifying Network-specific concepts, concerns about conflation of the GPRA data with CQI, and principles that might be studied more generally.