North Carolina Specialty Courts, Treatment Access, and the Substance Use Crisis: A Promising but Underfunded Model.

Treatment courts aim to reduce criminal recidivism by addressing the behavioral health care needs of persons with psychiatric or substance use disorders that contribute to their offending. Stable funding and access to behavioral health providers are crucial elements of success for the treatment court model. What happens when courts lose state funding and must rely on local initiatives and resources? In this study, a survey of North Carolina treatment court professionals identified resource gaps and unmet needs. The authors argue that continuing state investment could make treatment courts more viable and effective. Medicaid expansion is a potential new resource for these problem-solving courts.

Implementing Psychiatric Advance Directives: The Transmitter and Receiver Problem and the Neglected Right to Be Deemed Incapable.

Psychiatric advance directives (PADs) can help adults with serious mental illnesses preserve their autonomy and avoid involuntary interventions during an incapacitating mental health crisis. A PAD is a legal document prepared while mentally competent and states the person's treatment preferences to be implemented during a future crisis, ideally with the advocacy of an authorized proxy decision maker. PADs have been available in the United States for more than three decades but have yet to be robustly implemented in practice. This Open Forum describes PADs metaphorically as a device for remote communication among the person with mental illness, a proxy decision maker, and health care providers. Barriers to PAD usage occur on both "transmitter" and "receiver" sides and must be addressed to advance PAD implementation.

Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists.

BACKGROUND: A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams. AIMS: We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference. METHODS: Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1-2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis. RESULTS: There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment. CONCLUSIONS: PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Gun-Related and Other Violent Crime After Involuntary Commitment and Short-Term Emergency Holds.

This article presents a survival analysis of long-term risk of firearm-related and other violent crime in a large sample of adults with serious mental illness in Florida, comparing those who received a gun-disqualifying civil commitment after a short-term hold, those who were evaluated for commitment but were released or hospitalized voluntarily, and a third group with no holds or commitments. Among 77,048 adults with a diagnosis of schizophrenia-spectrum disorder, bipolar disorder, or major depression, 42.7 percent were detained for psychiatric examination under Florida's Baker Act; of that detained group, 8.4 percent were involuntarily committed while the remainder were released within 72 hours or agreed to voluntary admission. Over a follow-up period averaging six to seven years, 7.5 percent of the sample were arrested for a violent offense not involving a gun, and 0.9 percent were arrested for a violent crime involving a gun. A short-term hold with or without commitment was associated with a significantly higher risk of future arrest for violent crime, although the study population had other violence risk factors unrelated to mental illness. Risk of gun-involved crime, specifically, was significantly higher in individuals following a short-term hold only, but not in those who were involuntarily committed and became ineligible to purchase or possess guns. Policy implications are discussed.

Primary Care Providers And Specialists Deliver Comparable Buprenorphine Treatment Quality.

In response to rising numbers of opioid overdose deaths, primary care providers have been called on to play a greater role in delivering buprenorphine treatment for opioid use disorder. However, policy makers and providers have raised concerns that expanding treatment access may reduce treatment quality and that primary care providers are not well equipped to deliver buprenorphine treatment. We investigated two research questions in response to these concerns: How did buprenorphine treatment use and quality change in North Carolina Medicaid from 2014 to 2017, and how did buprenorphine treatment quality differ between primary care providers and specialists in North Carolina Medicaid during this period? We measured buprenorphine treatment quality as patients' retention in treatment and providers' adherence to treatment guidelines. We found that the number of enrollees receiving medication treatment for opioid use disorder increased substantially, but the percentage of enrollees with the disorder receiving treatment remained low. The quality of buprenorphine treatment increased during the study period, and primary care providers provided care of comparable or higher quality compared with that of other providers. Treatment quality for buprenorphine treatment is improving, but there remains room for improvement in both use and quality. Our results support the role of primary care providers in expanding treatment for opioid use disorder.

Gender-specific participation and outcomes among jail diversion clients with co-occurring substance use and mental health disorders.

Men and women with co-occurring substance use disorders and mental illness are at relatively high risk for becoming involved in the criminal justice system. Programs, such as post-booking jail diversion, aim to connect these individuals to community-based treatment services in lieu of pursuing criminal prosecution. Gender appears to have an important influence on risk factors and pathways through the criminal justice system, which in turn may influence how interventions like jail diversion work to engage men and women in treatment services and reduce recidivism. Different circumstances, levels of engagement, and outcomes by gender may be related to both person-level characteristics and external factors such as availability of gender-specific services and resources. This mixed-methods study identified specific ways in which men and women use services and reoffend after being diverted, and complemented those findings with in-depth insights from program clinicians about how program experiences and resources differ in important ways by gender. We matched and merged administrative records from 2007 to 2009 for 16,233 adults from several state agencies in Connecticut, and included data on demographic characteristics, clinical diagnoses, outpatient and inpatient behavioral health treatment utilization, arrest, and incarceration. Using propensity analysis, the 1693 men and women who participated in the statewide jail diversion program were matched to respective comparison groups of nondiverted men and women. We used longitudinal multivariable regression analyses to estimate the effects of jail diversion participation on treatment utilization, arrest, and incarceration, separately for men and women. We conducted three focus groups with jail diversion clinicians from around the state (n = 21) to gain in-depth insight from them about how circumstances, program experiences, and resources differ by gender in important ways; these subjective clinician insights complement the quantitative analyses of diversion outcomes for men and women. For both men and women, diversion was associated with reductions in risk for incarceration and increases in utilization of outpatient treatment services. For men only, diversion was associated with higher utilization of inpatient mental health care. No differences in treatment or criminal justice outcomes were observed in models that compared men and women directly. Major themes from the focus groups included: the existence of too few inpatient and residential resources for women with co-occurring disorders; different challenges to treatment engagement that men and women face; and a need for more effective, gender-specific services for all program participants. Results from this mixed-methods study offer information on gender-specific program outcomes and surrounding circumstances that can help programs to better understand and address unique risks and needs for men and women with co-occurring substance use and mental health disorders who are involved in the criminal justice system.

The effect of Medicaid expansion on use of opioid agonist treatment and the role of provider capacity constraints.

OBJECTIVE: To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates. DATA SOURCES: Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid. STUDY DESIGN: This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates. PRINCIPAL FINDINGS: The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance. CONCLUSIONS: Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access.

Criminal Justice and Suicide Outcomes with Indiana's Risk-Based Gun Seizure Law.

This article examines the application and effectiveness of a 2006 Indiana law designed to prevent gun violence by authorizing police officers to separate firearms from persons who present imminent or future risk of injury to self or others, or display a propensity for violent or emotionally unstable conduct. A court hearing is held to determine ongoing risk in these cases; a judge decides whether to return the seized firearms or retain them for up to five years. The study examines the frequency of criminal arrest as well as suicide outcomes for 395 gun-removal actions in Indiana. Fourteen individuals (3.5%) died from suicide, seven (1.8%) using a firearm. The study population's annualized suicide rate was about 31 times higher than that of the general adult population in Indiana, demonstrating that the law is being applied to a population genuinely at high risk. By extrapolating information on the case fatality rate for different methods of suicide, we calculated that one life was saved for every 10 gun-removal actions, similar to results of a previous study in Connecticut. Perspectives from key stakeholders are also presented along with implications for gun policy reform and implementation.

Medication-Assisted Treatment for Alcohol-Dependent Adults With Serious Mental Illness and Criminal Justice Involvement: Effects on Treatment Utilization and Outcomes.

OBJECTIVE: Adults with serious mental illness and comorbid alcohol dependence are at high risk for both high utilization of crisis-driven health care services and criminal justice involvement. Evidence-based medication-assisted treatment (MAT) for alcohol dependence may reduce both crisis service utilization and criminal recidivism. The authors estimated the effect of MAT on behavioral health treatment utilization and criminal justice outcomes for this population. METHOD: Relevant administrative data were merged from several public agencies in Connecticut for 5,743 adults ≥18 years old who had schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder comorbid with moderate to severe alcohol dependence and who were incarcerated for at least one night during the study window (2002-2009). Longitudinal multivariable regression models were used to estimate the effect of MAT compared with other outpatient substance abuse treatments on inpatient mental health and substance abuse hospitalizations, emergency department visits, criminal convictions, and incarcerations. RESULTS: MAT was associated with significant improvements in clinical outcomes in the 12 months following initiation compared with non-MAT comparison treatment, including greater reductions in mental health hospitalization and emergency department visits and greater improvements in psychotropic medication adherence. No benefits of MAT were found for most criminal justice outcomes, except for significant reductions in felony convictions among adults with bipolar disorder. CONCLUSIONS: MAT is underused for treating alcohol dependence, especially among adults with serious mental illness. These results suggest that MAT can have important benefits for clinical outcomes in this population. More research is needed to improve its use in this patient population as well as to address barriers to its availability.

Associations between pharmacotherapy for opioid dependence and clinical and criminal justice outcomes among adults with co-occurring serious mental illness.

Adults suffering from a serious mental illness (SMI) and a substance use disorder are at especially high risk for poor clinical outcomes and also arrest and incarceration. Pharmacotherapies for treating opioid dependence could be a particularly important mode of treatment for opioid-dependent adults with SMI to lower their risk for overdose, high-cost hospitalizations, repeated emergency department visits, and incarceration, given relapse rates are very high following detoxification in the absence of one of the three FDA-approved pharmacotherapies. This study estimates the effects of methadone, buprenorphine, and oral naltrexone on clinical and justice-related outcomes in a sample of justice-involved adults with SMI, opioid dependence, and criminal justice involvement. Administrative data were merged from several public agencies in Connecticut for 8736 adults 18years of age or older with schizophrenia spectrum disorder, bipolar disorder, or major depression; co-occurring moderate to severe opioid dependence; and who also had at least one night in jail during 2002-2009. Longitudinal multivariable regression models estimated the effect of opioid-dependence pharmacotherapy as compared to outpatient substance abuse treatment without opioid-dependence pharmacotherapy on inpatient substance abuse or mental health treatment, emergency department visits, criminal convictions, and incarcerations, analyzing instances of each outcome 12months before and after an index treatment episode. Several baseline differences between the study groups (opioid-dependence pharmacotherapy group versus outpatient treatment without opioid-dependence pharmacotherapy) were adjusted for in the regression models. All three opioid-dependence pharmacotherapies were associated with reductions in inpatient substance abuse treatment, and among the oral naltrexone subgroup, also reductions in inpatient mental health treatment, as well as improved adherence to SMI medications. Overall, the opioid-dependence pharmacotherapy group had higher rates of arrest and incarceration in the follow-up period than the comparison group; but those using oral naltrexone had lower rates of arrest (including felonies). The analysis of observational administrative data provides useful population-level estimates but also has important limitations that preclude conclusive causal inferences. Large reductions in crisis-driven service utilization associated with opioid-dependence pharmacotherapy in this study suggest that evidence-based medications for treating opioid dependence can be used successfully in adults with SMI and should be considered more systematically during assessments of treatment needs for this population.

Extended-release naltrexone and drug treatment courts: Policy and evidence for implementing an evidence-based treatment.

With insufficient access to treatment and a tradition of criminalizing addiction, people with substance use disorders - including opioid dependence - are more likely to be incarcerated than they are to receive the treatment they need. Drug treatment courts aim to address this problem, engaging their participants in substance use treatment in lieu of incarceration. Drug courts offer an especially important window of opportunity to connect opioid-dependent participants to extended-release naltrexone (XR-NTX), at a time when they are under highly-structured court supervision and required to detoxify from opioids to participate. Given the high cost of XR-NTX and high rates of uninsurance in the drug court population, new rigorous cost-effectiveness evidence is needed to demonstrate the extent to which XR-NTX improves program outcomes, including by reducing recidivism. With that new evidence, drug courts and the counties in which they are situated can make informed and difficult policy decisions about funding XR-NTX for some of their highest-risk community members.

Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams.

OBJECTIVE: Psychiatric advance directives (PADs) provide a legal mechanism for competent adults to document care preferences and authorize a surrogate to make treatment decisions. In a controlled research setting, an evidence-based intervention, the facilitated psychiatric advance directive (FPAD), was previously shown to overcome most barriers to PAD completion. This study examined implementation of the FPAD intervention in usual care settings as delivered by peer support specialists and nonpeer clinicians on assertive community treatment (ACT) teams. METHODS: A total of 145 ACT consumers were randomly assigned, within teams, to FPAD with facilitation by either a peer (N=71) or a clinician (N=74). Completion rates and PAD quality were compared with the previous study's standard and across facilitator type. Logistic regression was used to estimate effects on the likelihood of PAD completion. RESULTS: The completion rate of 50% in the intent-to-treat sample (N=145) was somewhat inferior to the prior standard (61%), but the rate of 58% for the retained sample (those who completed a follow-up interview, N=116) was not significantly different from the standard. Rates for peers and clinicians did not differ significantly from each other for either sample. PAD quality was similar to that achieved in the prior study. Four consumer variables predicted completion: independent living status, problematic substance use, length of time served by the ACT team, and no perceived unmet need for hospitalization in crisis. CONCLUSIONS: Peers and clinicians can play a crucial role in increasing the number of consumers with PADs, an important step toward improving implementation of PADs in mental health care.

Involuntary Outpatient Commitment and the Elusive Pursuit of Violence Prevention.

OBJECTIVE: Involuntary outpatient commitment (OPC)-also referred to as 'assisted outpatient treatment' or 'community treatment orders'-are civil court orders whereby persons with serious mental illness and repeated hospitalisations are ordered to adhere to community-based treatment. Increasingly, in the United States, OPC is promoted to policy makers as a means to prevent violence committed by persons with mental illness. This article reviews the background and context for promotion of OPC for violence prevention and the empirical evidence for the use of OPC for this goal. METHOD: Relevant publications were identified for review in PubMed, Ovid Medline, PsycINFO, personal communications, and relevant Internet searches of advocacy and policy-related publications. RESULTS: Most research on OPC has focussed on outcomes such as community functioning and hospital recidivism and not on interpersonal violence. As a result, research on violence towards others has been limited but suggests that low-level acts of interpersonal violence such as minor, noninjurious altercations without weapon use and arrests can be reduced by OPC, but there is no evidence that OPC can reduce major acts of violence resulting in injury or weapon use. The impact of OPC on major violence, including mass shootings, is difficult to assess because of their low base rates. CONCLUSIONS: Effective implementation of OPC, when combined with intensive community services and applied for an adequate duration to take effect, can improve treatment adherence and related outcomes, but its promise as an effective means to reduce serious acts of violence is unknown.

Gun Violence, Mental Illness, And Laws That Prohibit Gun Possession: Evidence From Two Florida Counties.

Gun violence kills about ninety people every day in the United States, a toll measured in wasted and ruined lives and with an annual economic price tag exceeding $200 billion. Some policy makers suggest that reforming mental health care systems and improving point-of-purchase background checks to keep guns from mentally disturbed people will address the problem. Epidemiological research shows that serious mental illness contributes little to the risk of interpersonal violence but is a strong factor in suicide, which accounts for most firearm fatalities. Meanwhile, the effectiveness of gun restrictions focused on mental illness remains poorly understood. This article examines gun-related suicide and violent crime in people with serious mental illnesses, and whether legal restrictions on firearm sales to people with a history of mental health adjudication are effective in preventing gun violence. Among the study population in two large Florida counties, we found that 62 percent of violent gun crime arrests and 28 percent of gun suicides involved individuals not legally permitted to have a gun at the time. Suggested policy reforms include enacting risk-based gun removal laws and prohibiting guns from people involuntarily detained in short-term psychiatric hospitalizations.

Influence of Criminal Justice Involvement and Psychiatric Diagnoses on Treatment Costs Among Adults With Serious Mental Illness.

The impact of criminal justice involvement and clinical characteristics on the cost of public treatment services for adults with serious mental illnesses is unknown. The authors examined differential effects of justice involvement on behavioral health treatment costs by primary psychiatric diagnosis (schizophrenia or bipolar disorder) and also by substance use diagnosis among 25,133 adult clients of Connecticut's public behavioral health system in fiscal years 2006 and 2007. Justice-involved adults with schizophrenia had the highest costs, strongly driven by forensic hospitalizations. Addressing the cross-system burdens of forensic hospitalizations may be a sensible starting point in the effort to reduce costs in both the public behavioral health and justice systems.

Treatment participation and medication adherence: effects on criminal justice costs of persons with mental illness.

Little empirical research has directly examined the extent to which early and consistent participation in outpatient services and adherence to prescribed psychotropic medications after a psychiatric hospitalization can help people with serious mental illnesses avoid arrest and incarceration and what impact this might have on state and local costs. The authors examined effects of medication adherence in the first 90 days after a psychiatric hospitalization among 1,367 adults with schizophrenia or bipolar disorder served by the public behavioral health systems of Miami-Dade County and Pinellas County in Florida. Better adherence was associated with lower subsequent criminal justice costs and greater use of treatment services. A modest investment in promoting treatment participation and medication adherence may reduce criminal justice involvement and costs for persons with serious mental illness.

Mental health and reoffending outcomes of jail diversion participants with a brief incarceration after arraignment.

OBJECTIVE: Jail diversion programs strive to divert offenders with mental illness from prosecution and into mental health treatment. Participants sometimes spend a short time in jail after arraignment, either because treatment resources are not immediately available or because judges want to increase their motivation for treatment. This study explored the effects of short jail stays before jail diversion ("jail first") on participants' postdiversion service use and reoffending. METHODS: The data were merged administrative records from public behavioral health and criminal justice systems in Connecticut for 712 adults with serious mental illness who participated in the jail diversion program during fiscal years 2005-2007. The effects on treatment receipt, crisis-driven service use, and reoffending during the six months postdiversion among jail first participants (N=102) versus a propensity-matched sample of participants who were diverted immediately (N=102) were estimated. RESULTS: Jail first participants had greater improvements in receipt of psychotropic medication during the follow-up compared with their counterparts who were diverted immediately. However, compared with participants who were immediately diverted, they did not have greater reductions in crisis-driven service use or reoffending and the time to reincarceration was shorter. CONCLUSIONS: Short stays in jail before diversion did not appear to be associated with improved mental health and reoffending outcomes, even though they appeared to improve receipt of psychotropic medication. Further research is needed to better understand the relationships between jail first, receipt of psychotropic medication, and broader health and offending outcomes, with a focus on identifying missing links that address criminogenic risks and participants' more intensive social service needs.