Recovery incentives program: California's contingency management benefit.

OBJECTIVE: The role of methamphetamine and cocaine use in California's drug poisoning (overdose) crisis has dramatically increased in the past five (5) years and has disproportionately affected American Indian, Alaska Native, and Black Californians. No FDA-approved medications currently exist for the treatment of individuals with stimulant use disorder (StimUD). Outside the Veteran's Administration, the Recovery Incentives Program: California's Contingency Management Benefit is the first large scale implementation of contingency management (CM). CM is the behavioral treatment with the most evidence and largest effect sizes for StimUD. METHODS: The Program uses a CM protocol where participants can receive a maximum of $599 over a six-month period, contingent upon 36 stimulant-negative urine test results. Urine tests are conducted using a set of approved, CLIA-waived, point-of-care urine drug tests (UDTs). To ensure fidelity to the CM protocol and to prevent fraud, waste, and abuse, all aspects of incentive accounting and distribution are managed electronically via a custom-developed software system. Incentive distribution utilizes electronic gift cards. A significant innovation of the project is the conceptualization of the CM Coordinator, a designated and highly trained and supervised individual responsible for all aspects of CM operation in a specific site. RESULTS AND CONCLUSIONS: The California Department of Health Care Services contracted with UCLA to develop and implement a robust evaluation of the Program; goals include evaluating the effectiveness of real-world implementation and facilitating quality improvement. The project will likely significantly impact the use of CM for StimUD nationally and may well reduce stimulant-related drug poisoning deaths.

Racial dynamics among clients in a residential substance use disorder treatment program in South Los Angeles and its impact on clients' treatment experiences.

This study seeks to investigate racial dynamics among clients in a female-only residential substance use disorder treatment facility in South Los Angeles and its effects on treatment experiences. Clients were interviewed about their interracial interactions, perceptions of clients of races and ethnicities different from their own and how racial dynamics might affect their experiences in treatment. Nine interviews were conducted and analyzed using thematic analysis. Participants recounted that racial differences do not play a significant role in their treatment experiences, although racial identities shape social group formation. Motivation to recover from addiction and other shared lived experiences facilitate interracial harmony.

Cost-Effectiveness of Publicly Funded Treatment of Opioid Use Disorder in California.

Background: Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations. Objective: To determine the cost-effectiveness of OAT for all treatment recipients compared with the observed standard of care for patients presenting with opioid use disorder to California's publicly funded treatment facilities. Design: Model-based cost-effectiveness analysis. Data Sources: Linked population-level administrative databases capturing treatment and criminal justice records for California (2006 to 2010); published literature. Target Population: Persons initially presenting for publicly funded treatment of opioid use disorder. Time Horizon: Lifetime. Perspective: Societal. Intervention: Immediate access to OAT with methadone for all treatment recipients compared with the observed standard of care (54.3% initiate opioid use disorder treatment with medically managed withdrawal). Outcome Measures: Discounted quality-adjusted life-years (QALYs) and discounted costs. Results of Base-Case Analysis: Immediate access to OAT for all treatment recipients costs less (by $78 257), with patients accumulating more QALYs (by 0.42) than with the observed standard of care. In a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, total lifetime savings for this cohort could be as high as $3.8 billion. Results of Sensitivity Analysis: 99.6% of the 2000 simulations resulted in lower costs and more QALYs. Limitation: Nonrandomized delivery of OAT or medically managed withdrawal. Conclusion: The value of publicly funded treatment of opioid use disorder in California is maximized when OAT is delivered to all patients presenting for treatment, providing greater health benefits and cost savings than the observed standard of care. Primary Funding Source: National Institute on Drug Abuse.

Comparative Effectiveness of California's Proposition 36 and Drug Court Programs Before and After Propensity Score Matching.

California's voter-initiated Proposition 36 (Prop 36) program is often unfavorably compared to drug courts, but little is empirically known about the comparative effectiveness of the two approaches. Using statewide administrative data, analyses were conducted on all Prop 36 and drug court offenders with official records of arrest and drug treatment. Propensity score matching was used to create equivalent groups, enabling comparisons of success at treatment discharge, recidivism over 12 months post-treatment entry, and magnitude of behavioral changes. Significant behavioral improvements occurred for both Prop 36 and drug court offenders, but while more Prop 36 offenders were successful at discharge, more recidivated over 12 months. Core programmatic differences likely contributed to differences in outcomes. Policy implications are discussed.

Adult use cannabis legalization and cannabis use disorder treatment in California, 2010-2021.

INTRODUCTION: Many nations and jurisdictions have legalized non-medical adult use of cannabis, or are considering doing so. This paper contributes to knowledge of adult use legalization's associations with cannabis use disorder (CUD) treatment utilization. METHODS: This study collected data from a dataset of all publicly funded substance use disorder treatment delivered in California from 2010 to 2021 (1,460,066 episodes). A logistic regression model estimates adult use legalization's impacts on CUD treatment utilization using an individual-level pre-post time series model, including individual and county-level characteristics and county and year-fixed effects. RESULTS: Adult use legalization was associated with a significant decrease in the probability of admission to CUD treatment (average marginal effect (AME): -0.005, 95 % CI: -0.009, 0.000). Adult use legalization was also associated with a decrease in the probability of admission to CUD treatment for males (AME: -0.025, 95 % CI: -0.027, -0.023) Medi-Cal beneficiaries (AME: -0.025, 95 % CI: -0.027, -0.023) adults ages 21+ (AME: -0.011, 95 % CI: -0.014, -0.009) and Whites (AME: -0.012, 95 % CI: -0.015, -0.010), and an increase in the probability of admission to CUD treatment for patients referred from the criminal justice system (AME: 0.017, 95 % CI: 0.015, 0.020) and Blacks (AME: 0.004, 95 % CI: 0.000, 0.007) and Hispanics (AME: 0.009, 95 % CI: 0.006, 0.011). CONCLUSIONS: Adult use legalization is associated with declining CUD treatment admissions, even though cannabis-related problems are becoming more prevalent. Policies and practices that protect public health, and engage people with CUD in treatment are needed.

Offender diversion into substance use disorder treatment: the economic impact of California's proposition 36.

OBJECTIVES: We determined the costs and savings attributable to the California Substance Abuse and Crime Prevention Act (SACPA), which mandated probation or continued parole with substance abuse treatment in lieu of incarceration for adult offenders convicted of nonviolent drug offenses and probation and parole violators. METHODS: We used individually linked, population-level administrative data to define intervention and control cohorts of offenders meeting SACPA eligibility criteria. Using multivariate difference-in-differences analysis, we estimated the effect of SACPA implementation on the total and domain-specific costs to state and county governments, controlling for fixed individual and county characteristics and changes in crime at the county level. RESULTS: The additional costs of treatment were more than offset by savings in other domains, primarily in the costs of incarceration. We estimated the statewide policy effect as an adjusted savings of $2317 (95% confidence interval = $1905, $2730) per offender over a 30-month postconviction period. SACPA implementation resulted in greater incremental cost savings for Blacks and Hispanics, who had markedly higher rates of conviction and incarceration. CONCLUSIONS: The monetary benefits to government exceeded the additional costs of SACPA implementation and provision of treatment.

The Effect of the Drug Medi-Cal Organized Delivery System 1115 Demonstration Waiver on Substance Use Disorder Treatment Access: Evidence from California.

BACKGROUND: In August 2015, the California Department of Health Care Services created the Drug Medi-Cal Organized Delivery System 1115 demonstration waiver (DMC-ODS waiver) to improve service delivery to Medi-Cal-eligible individuals with a substance use disorder (SUD). We examine if implementing the DMC-ODS waiver across California counties improved patient access to SUD treatment services. METHODS: We use administrative data from 2016 to 2020 from a reporting system for all publicly-funded SUD treatment services delivered in California and employ difference-in-differences and event study empirical strategies exploiting the differential timing of DMC-ODS waiver adoption across counties. RESULTS: Event study analyses show that eleven or more months after the introduction of the DMC-ODS waiver, the number of unique patient admissions significantly increase by nearly 20%. Residential treatment admissions significantly increase by roughly 25% in all months post-waiver introduction. CONCLUSIONS: This study provides valuable information for policymakers about implementing 1115 waivers, and the important public health implications. California's DMC-ODS waiver has demonstrated that 1115 waivers similar to it can likely increase access to SUD treatment.

The California Integration Learning Collaborative: a forum to address challenges of SUD-primary care service integration.

The California Substance Use Disorder (SUD)/Health Care Integration Learning Collaborative (CILC) aims to provide an interactive forum where county administrators, SUD provider organization representatives, and other key stakeholders can collaborate to identify successful models and processes for SUD integration into primary health care, as well as common barriers and solutions. We present the topics discussed within the CILC that have focused on common barriers to SUD and health care integration (documentation/data privacy, financing, and partnering with primary care providers). This article describes the discussions, presentations, and lessons learned from the CILC addressing each of these three barriers.

Integrating substance use disorder services with primary care: the experience in California.

Integrating substance use disorder (SUD) services with primary care (PC) can improve access to SUD services for the 20.9 million Americans who need SUD treatment but do not receive it, and help prevent the onset of SUDs among the 68 million Americans who use psychoactive substances in a risky manner. We lay out the reasons for integrating SUD and PC services and then explore the models used and the experiences of providers as they have begun SUD/PC integration in California.

Perceptions of mental health and substance use disorder services integration among the workforce in primary care settings.

It is important to understand the perceptions of staff members who will be implementing the expected integration of mental health and substance use services into primary care. Surveys were administered to mental health/substance use disorder (MH/SUD) staff, support staff (SS), and primary care providers (PCPs) from three organizations (seven sites) that were participating in an initiative to promote the integration of MH/SUD services into primary care in Kern County, California. Results suggest that integration and MH/SUD services are highly valued among all staff types, and that staff are uniformly interested in further MH/SUD training. However, there were significant differences in staff perceptions. MH/SUD staff and services were valued by PCPs more than MH/SUD staff perceived being valued by PCPs, and MH/SUD staff were less likely to agree that communication with PCPs was good. Information seemed to flow better from MH/SUD staff to PCPs than in the other direction.

Homelessness and publicly funded substance use disorder treatment in California, 2016-2019: Analysis of treatment needs, level of care placement, and outcomes.

INTRODUCTION: Both homelessness and substance use have increased in recent years. People experiencing homelessness (PEH) are at increased risk for health problems and early mortality, both of which can be exacerbated by substance use disorders (SUD). Specialty SUD treatment is likely needed to address substance use among PEH, and more than 232,000 PEH received treatment from U.S. publicly funded SUD programs in 2015. The objective of this paper is to develop a better understanding of the SUD services that PEH receive in publicly funded treatment programs by (1) describing the characteristics and needs of the PEH population served in publicly funded SUD treatment programs, compared to non-PEH populations; (2) determining if differences exist in treatment placement (level of care) for PEH and non-PEH; and (3) gauging how successful programs are in treating PEH compared to non-PEH. METHODS: Observational study using a two-way fixed effect model to determine associations among homelessness, retention, and outcomes among Medicaid beneficiaries receiving SUD treatment in California from 2016 to 2019 (n = 638,953). The study team used ordinary least squares (OLS) regression to measure the degree to which homelessness was associated with baseline characteristics, SUD services received, and treatment outcomes. RESULTS: PEH were significantly more likely than non-PEH to be having methamphetamine or heroin as their primary substance. PEH had greater frequency of primary substance use prior to entering treatment, greater ER and hospital utilization, more criminal justice involvement, and greater prevalence of mental health diagnoses and unemployment. PEH were 9.82% more likely than non-PEH to receive residential treatment and 7.11% less likely than non-PEH to receive treatment intensive outpatient modalities. Homelessness was associated with an 11.90% decrease in retention, and a 19.40% decrease in successful discharge status. These trends were consistent across outpatient, intensive outpatient, and residential modalities. CONCLUSIONS: Developing SUD treatment capacity and housing supports can improve treatment outcomes for PEH. Potential strategies to improve SUD services for PEH include providing more contingency management, opioid pharmacotherapies, programming designed to treat individuals with co-occurring mental health disorders, and resources for housing options that can support PEH in their recovery.

Development and Measurement of the Treatment Perceptions Survey (TPS) for Clients with Substance Use Disorders.

Statistical reliability of the Treatment Perceptions Survey (TPS) questionnaire was examined using data from 19 California counties. The 14-item TPS was designed for clients receiving substance use disorder services at publicly funded community-based programs. The TPS is being used for evaluation of the State's 1115 Medicaid Waiver, external quality review of county-based systems of care, and quality improvement efforts. The survey addresses four domains of access to care, quality of care, care coordination, and general satisfaction that each include multiple items, plus a single item focused on self-reported outcome. Reliability test results of the four domains as composite measures were statistically significant. General satisfaction ratings were the best predictor of self-reported outcome in a path analysis model, followed by ratings of care coordination and quality of care. Separate analyses of TPS data from clients receiving specialty mental health services suggest the questionnaire can also be used reliably in mental health settings.

Medical conditions of primary care patients with documented cannabis use and cannabis use disorder in electronic health records: a case control study from an academic health system in a medical marijuana state.

BACKGROUND: Approximately 3.8% of adults worldwide have used cannabis in the past year. Understanding how cannabis use is associated with other health conditions is crucial for healthcare providers seeking to understand the needs of their patients, and for health policymakers. This paper analyzes the relationship between documented cannabis use disorders (CUD), cannabis use (CU) and other health diagnoses among primary care patients during a time when medical use of marijuana was permitted by state law in California, United States of America. METHODS: The study utilized primary care electronic health record (EHR) data from an academic health system, using a case-control design to compare diagnoses among individuals with CUD/CU to those of matched controls, and those of individuals with CUD diagnoses with individuals who had CU otherwise documented. Associations of documented CU and CUD with general medical conditions and health conditions associated with cannabis use (both medical and behavioral) were analyzed using conditional logistic regression. RESULTS: Of 1,047,463 patients with ambulatory encounters from 2013-2017, 729 (0.06%) had CUD diagnoses and 3,731 (0.36%) had CU documented in their EHR. Patients with documented CUD and CU patients had significantly (p < 0.01) higher odds of most medical and behavioral diagnoses analyzed. Compared to matched controls, CUD-documented patients had highest odds of other substance use disorders (OR = 21.44: 95% CI 9.43-48.73), any mental health disorder (OR = 6.99; 95% CI 5.03-9.70) social anxiety disorder (OR = 13.03; 95% CI 2.18-77.94), HIV/AIDS (OR = 7.88: 95% CI 2.58-24.08), post-traumatic stress disorder (OR = 7.74: 95% CI 2.66-22.51); depression (OR = 7.01: 95% CI 4,79-10.27), and bipolar disorder (OR = 6.49: 95% CI 2.90-14.52). Compared to matched controls, CU-documented patients had highest odds of other substance use disorders (OR = 3.64; 95% CI 2.53-5.25) and post-traumatic stress disorder (OR = 3.41; 95% CI 2.53-5.25). CUD-documented patients were significantly more likely than CU-documented patients to have HIV/AIDS (OR = 6.70; 95% CI 2.10-21.39), other substance use disorder (OR = 5.88; 95% CI 2.42-14.22), depression (OR = 2.85; 95% CI 1.90-4.26), and anxiety (OR = 2.19: 95% CI 1.57-3.05) diagnoses. CONCLUSION: The prevalence of CUD and CU notation in EHR data from an academic health system was low, highlighting the need for improved screening in primary care. CUD and CU documentation were associated with increased risk for many health conditions, with the most elevated risk for behavioral health disorders and HIV/AIDS (among CUD-documented, but not CU-documented patients). Given the strong associations of CUD and CU documentation with health problems, it is important for healthcare providers to be prepared to identify CU and CUD, discuss the pros and cons of cannabis use with patients thoughtfully and empathically, and address cannabis-related comorbidities among these patients.

Treatment outcomes for methamphetamine users: California Proposition 36 and comparison clients.

Methamphetamine (meth) is a major drug of abuse in California and several other states, particularly among criminal offender populations. Over the past decade, substance abuse treatment systems have had to adapt to and accommodate the increasing needs of meth users and, in California, deal with the impact of Proposition 36, which has resulted in a greater number of criminal offenders entering the treatment system. This study examines selected treatment performance and outcome indicators for California Proposition 36 offenders entering substance abuse treatment for meth use and compares their performance and outcomes to other subgroups of California treatment clients differentiated by whether or not they were admitted to treatment through Proposition 36 and whether or not their primary substance was meth. Significant improvements in all outcome domains were seen across the populations, and treatment performance and outcomes were not substantively inferior for the offender or meth-using groups.

Editors' introduction: Identifying and assessing promising practices for criminal justice clients--California Substance Abuse Research Consortium (SARC) meetings, 2010.

Although some practices clearly have stronger supporting evidence than others, a single authoritative list of evidence-based practices (EBPs) that can be applied in the treatment of criminal justice clients does not exist. Nationally, use of EBPs is low, and such practices are generally only implemented under certain circumstances. To clarify these issues, experts from around the nation were invited to California for two research-to-policy meetings focused on EBP identification and implementation. Their presentations and the resulting series of articles in this special theme issue describe the current state of EBP research for criminal justice clients. To advance the field beyond the compilation of EBP lists, which can only represent a partial solution at best, next steps should include a greater focus on quality of implementation, intensity of quality assurance and monitoring, and training for underlying skills and principles.

Treating opioid use under California's Proposition 36: differential outcomes by treatment modality.

In California, Proposition 36 (Prop. 36) has led to positive outcomes for a significant proportion of participants-increases in drug treatment completion, reduced drug use and recidivism, and increased employment. However, there are notable differences in outcomes among Prop. 36 subgroups, with some of the poorest outcomes observed among opioid users. This may be because very few Prop. 36 opioid users were placed in narcotic treatment programs (NTPs). Prop. 36 opioid users who were placed in NTPs using methadone had the greatest reductions in opioid use from treatment intake to discharge, as compared to Prop. 36 opioid users who received outpatient drug-free or residential treatment. As such, NTPs should be considered to be a highly efficacious and viable treatment option for Prop. 36 opioid users. Thus, to improve treatment outcomes among Prop. 36 opioid users, it is essential that the provision and utilization of NTPs be enhanced.

Opening the "black box": Four common implementation strategies for expanding the use of medications for opioid use disorder in primary care.

Background: Despite the persistent increase in overdose deaths, access to medications for opioid use disorders remains limited. Recent federal funding aimed at increasing access prompts a need to understand if implementation strategies improve access. Methods: This is an analysis of data from 174 primary care clinics enrolled in a state-wide medications for opioid use disorders (MOUD) implementation effort in California. We examined clinic use of one of four implementation strategies: learning collaboratives, Project Extension for Community Health care Outcomes (ECHO), didactic webinars, and clinical skills trainings. The primary implementation outcome was categorical change in new patients prescribed buprenorphine. Univariate and multivariate logistic regressions were used to determine the impact of clinic attendance in all or individual implementation strategies, respectively, on patient growth. Results: Clinics attending learning collaboratives, Project ECHO, and clinical skills trainings had significantly higher odds of patient growth (odds ratio [OR] = 3.56; 95% confidence interval [CI] = 1.78, 7.10, p < .001), (OR = 3.39; 95% CI = 1.59, 7.24, p < .01), (OR = 3.90, 95% CI = 1.64, 9.23, p < .01) than non-attending clinics. The impact of attendance at learning collaboratives (OR = 5.81, 95% CI = 1.89, 17.85; p < .01), didactic webinars (OR = 3.59; 95% CI = 1.04, 12.35; p < .05), and clinical skills trainings (OR = 3.53, 95% CI = 1.06, 11.78, p < .05) on patient growth was greater for Federally Qualified Health Centers. When comparing strategies in multivariate models, only the relationship between learning collaborative attendance and new patients prescribed buprenorphine remained significant (OR = 2.57; 95% CI = 1.12, 5.88; p < .05). Conclusions: This study reported on a large, statewide, implementation-as-usual project offering four typical implementation strategies. Clinic attendance at learning collaboratives, a multi-component strategy, had the most consistent impact on new patients prescribed buprenorphine. These results suggest that while a broad array of strategies was initially reasonable, optimizing the selection of implementation strategies could be more effective. Plain Language Summary: Access to life-saving medications for opioid use disorder, such as buprenorphine, remains limited despite strong evidence of effectiveness. Systems and organizations often select from a variety of implementation strategies aimed at expanding access to these medications. However, scant research exists to enable these organizations to select the most effective and efficient strategies. Our study-within a large state-wide system of care-examined the impact of primary care clinic attendance in four common implementation strategies on new patients prescribed buprenorphine. Learning collaboratives were the strategy that most consistently improved outcomes. These results highlight the challenges to strategy selection inherent in implementation-as-usual systems-level approaches. The field needs evidence-based information on which implementation strategies are most likely to yield desired implementation outcomes.

Improving the accountability of California's public substance abuse treatment system through the implementation of performance models.

Improving the care for individuals with substance use disorders is a national health policy priority. Like other parts of the health care system, the addiction field is under pressure for higher accountability-more efficient use of treatment resources, the delivery of quality services, and the production of positive client outcomes. This introductory article highlights the importance of the collection of articles being published in this special issue as they describe California's efforts toward making the alcohol and drug (AOD) treatment system more accountable and effective.

Preliminary results of the evaluation of the California Hub and Spoke Program.

In August 2017, California launched the Hub and Spoke Program to address the growing number of opioid overdose deaths in the state. The program connects opioid treatment programs ("hubs") with office based opioid treatment settings, like primary care clinics ("spokes") to build a network of treatment expertise and referral resources. A key objective of this program is to expand access to medications for opioid use disorders (MOUD), with a particular focus on getting more buprenorphine into spokes. This article describes the preliminary results of the evaluation of the California Hub and Spoke program. Using a mixed methods approach, this portion of the evaluation measures changes in numbers of MOUD patients and providers, and barriers and facilitators to implementation. Findings reveal that, in the first 15 months of the program, 3480 new patients started buprenorphine in 118 spokes, increasing treatment initiations by 94.7% over baseline. The number of waivered spoke providers also increased 52.4% to 268. Although these data demonstrate promising growth in the network, challenges to expanding treatment access remain. Provider activity was among the most notable. Despite growth in the number of spoke providers with waivers to prescribe buprenorphine, only 68.7% (n = 184) were actively prescribing to patients. A survey of providers found that those who were not yet using their waivers lacked the confidence and mentorship they needed to prescribe. Provider knowledge and attitudes toward MOUD, fear of legal consequences, and limited patient outreach were also contributing factors. Recommendations for strengthening Hub and Spoke program implementation include facilitating mentor linkage for prescribers, expanding the support offered to spoke providers, and offering additional training and technical assistance aimed at provider stigma. Efforts to address these recommendations are described in a companion paper (Miele et al., under review).

Crossed categorization beyond the two-group model.

Four studies examined processing of in-group and out-group information with stimuli that are more complex than those used in previous crossed categorization studies. A diverse set of predictions is generated by previous theoretical work to account for how participants will integrate information stemming from multiple group memberships. Heuristic, threshold-based processing of information was supported over algebraic processing. Participants appeared to divide stimuli into "in-grouplike" and "out-grouplike" metacategories. However, the threshold at which this distinction was made, and whether it was based on in-group favoritism or out-group derogation, was influenced by the nature of the situation and the task participants performed. Advantages of crossed categorization research that moves beyond the traditional two-group model are discussed.