Implementation in Community

(1)

M di

ti

A

i t d T

t

Medication-Assisted Treatment

Implementation in Community

C

ti

l E

i

t (MATICCE)

Correctional Environments (MATICCE)

CJ

(2)

What is Medication

What is Medication--Assisted

Assisted

What is Medication

What is Medication Assisted

Assisted

Treatment (MAT)?



MAT is the use of medications in combination with

counseling and behavioral therapies to provide a

h l

ti

t

h t th t

t

t f

b t

whole-patient approach to the treatment of substance

use disorders.



Medications address withdrawal craving &



Medications address withdrawal, craving &

reinforcing euphoria.



Research shows that when treating substance use

disorders, a combination of medication and

behavioral therapies is most successful.

(3)

Why Focus on MAT in Community

Corrections (Probation/Parole)?



MAT Planning Survey

 RCs surveyed all potential CJ partner sites (N=50)

 Demonstrated several barriers to using MAT in CJ settings:

 Perceptions that MATp  “available in the community”y

 Security/Liability issues

 Cost/Regulatory issues

 Lack of knowledge about effectiveness of MATac o o edge about e ect e ess o

 Philosophical opposition to MAT



Parole/Probation

sites:

 l t t f MAT

 lowest current use of MAT

 most potential for initiating/expanding MAT

CJ

(4)

Specific Barriers to Implementing MAT

in Community Corrections



Community Corrections (CC) defers responsibility to

y

(

)

p

y

existing community treatment providers but weak referral

relationships exist



Lack of knowledge about effectiveness



Philosophical opposition to MAT

Strategy for overcoming barriers:



Address staff knowledge/perceptions and work to improve



Address staff knowledge/perceptions and work to improve

working relationship between CC and existing community

treatment agencies (interorganizational linkages)

(5)

Specific Aims



Aim 1

: Improve service coordination between Community

Corrections agencies and local MAT-providing tx agencies.



Aim 2

: Improve CC agents’ knowledge perceptions and



Aim 2

: Improve CC agents knowledge, perceptions, and

information about referral resources and intent to refer

appropriate clients to community-based MAT.



Aim 3

: Increase the number of CC clients linked with MAT.



Aims will be accomplished by testing:

 a staff-level Knowledge, Perceptions, and Information (KPI) training intervention; and

 an interorganizational linkage intervention.

CJ

(6)

Two-Part Implementation

Strategy: Part 1



Knowledge, perception & information (KPI)



Training of CC staff and selected staff from



Training of CC staff and selected staff from

assessment & treatment agencies to address:

• lack of knowledge about effectiveness

g

• philosophical preference for abstinence-based

treatment

• Information and understanding about local MAT

resources



Delivered by regional Addiction Technology



Delivered by regional Addiction Technology

Transfer Centers (ATTCs) based on

NIDA/CSAT Blending Initiative materials

g

(7)

Slide 6

bh3 changed second check mark to specifically name the Blending Initiative

(8)

KPI Outline



Address Community Corrections (CC) perspectives on

MAT through open discussion



Basics of brain functioning in relation to MAT with



Basics of brain functioning in relation to MAT with

features of special interest to those in CJ professions



Medications used to treat alcoholism, evidence about

effectiveness and side effects



Medications used to treat opiates, evidence about

effectiveness and side effects

 Examples of typical CC clients who could benefit from MAT



Reasons that those under CC supervision with addiction

histories might be good candidates for MAT

 Rapid re-addiction after release, opiate overdose, alcohol and violent crime

(9)

KPI Outline, cont’d



Advantages that MAT might offer the criminal

justice system

 evidence-based practice

 reduced numbers of addicts going through repeated t i ti l l ld lik l lt i arrest-incarceration-release cycles would likely result in decreased in crime associated with addiction and in lower public safety costs

 f l li k ith di ti i t d t t t

 formal linkages with medication-assisted treatment agencies could simplify supervision and lower

parole/probation supervision costs



H

t d

id if

i

d

did t f



How to decide if someone is a good candidate for

referral to MAT



Types of agencies where MAT is typically offered



Types of agencies where MAT is typically offered

CJ

(10)

Two-Part Implementation Strategy



Part 2:

Interorganizational linkage

intervention (OLI)



Incorporates 3 aspects of CMHS ACCESS

intervention considered most effective



Pharmacotherapy Exchange Councils (PEC)

• Representatives from relevant local agencies

• Co-chaired by directors of CC and local MAT

providers (or designees)

• Charged to address linkage to MAT-enabled

providers

(11)

Two-Part Implementation Strategy



Organizational Linkage Intervention (OLI)



Strategic Planning by PEC



Strategic Planning by PEC

• Facilitated by local research team

• Address factors influencing linkages to MAT

A k l d l it f t

• Acknowledge complexity of system



“Connections Coordinator” Position

• Coordinate PEC activities; liaison, foster consensus among ; , g agencies

• Key person, trusted by all participants

CJ

(12)

PEC Membership

The PEC includes . . .

 Co-Chairs with the authority to change policy, or at least those who have direct communication to those with such authority

authority

 Dedicated Connections Coordinator who works closely with members of the PEC in carrying out the OLI

 S i d li t ff f ili ith i d ti

 Supervisory and line staff familiar with issues and operations

 Researcher (usually affiliated with the research center) who will be called upon to provide technical, administrative, and logistical support to the PEC

(13)

Overview of Phases for the

O

i ti

l Li k

I t

ti

(OLI)

O

i ti

l Li k

I t

ti

(OLI)

Organizational Linkage Intervention(OLI)

Phase

Phase Primary Outcome(s)Primary Outcome(s) Duration Duration

(in weeks) (in weeks)

Pre

Pre--PhasePhase Local PEC Team is formed and the MATICCE Local PEC Team is formed and the MATICCE project is introduced

project is introduced

1 1--22

1.

1. Needs Needs PEC completes a Needs Assessment that identifies PEC completes a Needs Assessment that identifies &

&

8 8--1212

Assessment

Assessment the relative strengths & weaknesses in the interthe relative strengths & weaknesses in the

inter--organizational practices associated with MAT organizational practices associated with MAT

2

2 StrategicStrategic PEC develops and adopts a Strategic Plan thatPEC develops and adopts a Strategic Plan that ₈_{8 --12}₁₂

2.

2. Strategic Strategic Planning Planning

PEC develops and adopts a Strategic Plan that PEC develops and adopts a Strategic Plan that identifies goals and objectives for improvements to identifies goals and objectives for improvements to increase the use of MAT

increase the use of MAT

8 8 1212

3

3 II ll t tit ti PECPEC k ik i ll bll b titi t it i ll tt ₁₆_{16 24}₂₄

3.

3. ImplementationImplementation PEC works in a collaborative manner to implement PEC works in a collaborative manner to implement the objectives and attain the goals identified in their the objectives and attain the goals identified in their Strategic Plan

Strategic Plan

16 16 -- 2424

4.

4. FollowFollow--UpUp PEC assesses the relative sustainability of both the PEC assesses the relative sustainability of both the ₂₄_{24 -- 32}₃₂

4.

4. FollowFollow UpUp yy

process improvement targets achieved and the PEC process improvement targets achieved and the PEC method for facilitating process improvements

method for facilitating process improvements

24 24 3232

(14)

Study Design

Jun -Nov 2010 Pre-Intervention Pilot Phase PHASE

Baseline Data Collection (all sites)

Jun -Nov 2010 (6 mo) PHASE 1 Oct –Dec 2010 (3 mo)

Pre Intervention Pilot Phase

Test chart data collection procedures

Knowledge, Attitude, Information (KPI) Intervention (all sites) RANDOMIZATION Jan –Feb ‘11 (2 mo) PHASE 2 Group 1 Linkage Intervention PEC Group 2 No Linkage Intervention PHASE 3 Feb ‘11-Dec ‘12 (12 mo) _PEC Strategic Planning Connection Coordinator Intervention (KPI only )

End-of-Phase 3 Data Collection (all sites)

3

(12 mo)

Jan’Feb‘12 (2 mo)

6-Month Follow-up Data Collection (all sites)

( )

Jun-Jul ‘12 (2 mo)

Analysis

(15)

Nineteen Site Study



Intervention based in community corrections (i.e.,

probation/parole)



Each CC office would identify at least one local addiction

pharmacotherapy-providing treatment agency to which

client referrals can be made

 opioid treatment programs providing methadone or buprenorphine

 outpatient programs providing bup or naltrexone for opioid dep. or naltrexone, acamprosate or disulfiram for alcohol dependence



Each RC would contribute at least 2 CJ sites to the

protocol, preferably in distinct geographic catchment areas

 Catchment area distinction helps avoid contamination (especially of tx providers) in the delayed implementation group

CJ

(16)

(17)

Sources of Data

SURVEY QUALITATIVE AGENCY RECORDS

INTERVIEWS

What: -interorganizational relations (IOR) between criminal justice and treatment agencies

Compliment and supplement the information from the

-Probation/parole and/or Tx agency records (electronic data, presentencing evaluations,

a d ea e age c es participating in the study

-knowledge perceptions and information (KPI) about MAT.

o a o o e surveys.

p ese e c g e a ua o s, contact records, formal

assessments, urinalysis results, etc.).

-Abstract 200 client files with ( )

evidence of opioid or alcohol use.

Who: Representative sample of -probation/parole personnel (director, supervisors, and POs) -treatment personnel (e.g.,

Selected

sub-sample of 4 survey respondents, 4 PEC members, and

-Researchers and trained

assistants, with cooperation of participating agencies.

treatment personnel (e.g., director, clinical supervisor, counselors, medical director). -All correctional staff with

members, and Connections Coordinator.

-All procedures approved by RC Institutional Review Boards to ensure compliance with Human Subjects requirements.

specialized substance abuse caseload

(18)

(19)

Hypothesis 1



CC units in the KPI+Linkage intervention will have

greater



relative to baseline in interorganizational

tx svc coordination than those with KPI alone.



Relates to

Aim 1

(improve service coordination)

C G 1 (KPI Li k ) & 2 (KPI) t d f Ph 3 • Compares Groups 1 (KPI+Linkage) & 2 (KPI) at end of Phase 3



Outcomes

• Baseline Survey of Organizational Characteristics (BSOC) • Baseline Survey of Organizational Characteristics (BSOC) • ACCESS measures (e.g., Morrissey et al., 2002)

• Interorg Relations Survey – adapted from Van de Ven, 1980



Data sources

• Semi-structured interviews & CC staff surveys at baseline & end of Phase 3

CJ

(20)

Hypothesis 2



After the KPI training, CC officers will have



knowledge/perceptions re: evidence for MAT use in

knowledge/perceptions re: evidence for MAT, use in

treatment, and where to refer clients



Relates to

Aim 2

(staff knowledge & intent)

(

g

)

• Compares staff baseline-post KPI training in both groups



Outcomes

O i i b t MAT S d t d f Fit ld & • Opinions about MAT Survey – adapted from Fitzgerald &

McCarty, 2009; Springer & Bruce, 2008; Gjersing et al. 2007



Data sources

(21)

Hypothesis 3



Staff in KPI + Linkage group will have greater



in

intent to refer clients to MAT vs KPI alone



Relates to

Aim 2

(staff knowledge & intent to refer)

• Compares Group 1 vs. Group 2 staff baseline-post Phase 3.



Outcomes



Outcomes

• Intent to refer on Likert-type scales (Varra et al., 2008)



Data sources

• CC staff surveys at baseline & end of Phase 3

CJ

(22)

Hypothesis 4





’d interorganizational tx service coordination and

staff knowledge / perceptions / referral practices will

be sustained 6 months after intervention period.



Relates to

Aim 1

(service coordination)

• Compares Group 1 vs Group 2 across all data collection periods • Compares Group 1 vs. Group 2 across all data collection periods



Outcomes

• Interorganizational coordination measures per H1 • KPI and intent to refer scales per H2, H3



Data sources

CC t ff i t t d i t i t b li d f • CC staff surveys, semi-structured interviews at baseline, end of

(23)

Hypothesis 5



CC units in KPI+Linkage group will have a greater



over baseline in % opioid/alcohol-using clients

referred to MAT assessment than KPI onl gro p

referred to MAT assessment than KPI only group.



Relates to

Aim 3

(increase client linkages)

• Compares Group 1 vs Group 2 across all data collection periodsCompares Group 1 vs. Group 2 across all data collection periods



Outcomes

• % opioid-/alcohol- using clients referred for assessment for MAT



Data sources

• CC records for 6 mos prior to baseline, last 6 months of Phase 3, and 6 months after Phase 3*

• Monthly CC officer survey for month prior to baseline, last 6 months of Phase 3, and 6 months after Phase 3, reporting:

– # opioid/alcohol-using clients# opioid/alcohol using clients

– # clients referred for MAT assessment

CJ

(24)

Hypothesis 6



CC units in KPI + Linkage group will have a greater



over baseline in clients assessed by a tx provider

for MAT and who initiate MAT, vs. KPI only group



Relates to

Aim 3

(increase client linkages)

• Compares Group 1 vs Group 2 staff baseline Phase 3 • Compares Group 1 vs. Group 2 staff baseline-Phase 3



Outcomes

• # completed CJ referrals for assessment, MAT initiates, person-days on MAT



Data sources

• Records abstract or report from substance abuse assessment • Records abstract or report from substance abuse assessment

provider and main MAT program for 6 mos prior to baseline & last 6 mos of Phase 3*

(25)

Hypothesis 7



CC units in KPI+Linkage group will have a larger



relative to baseline in opioid/alcohol-using clients

rearrested, re-incarcerated, & testing positive for

substance use relative to KPI only group.



R l t

t

Ai

3 (i

li

t li k

)



Relates to

Aim 3

(increase client linkages)

• Compares Group 1 vs. Group 2 staff baseline-Phase 3.



Outcomes:

Of “potentially MAT appropriate” CC clients i

p

y

pp p

• % arrested, reincarcerated, testing positive for drugs



Data sources

• Records abstract or report from CC, CJ and drug-testing program for 6 mos prior to baseline, last 6 mos of Phase 3, & 6 mos after Phase 3.

CJ

(26)

Challenges and Limitations



If site cannot accept randomization assignment

 MATICCE SMS will recommend action, incl replacement if necessary.



Protocol deviations



Protocol deviations

 Change in staff or level of cooperation • Retraining

• Analyses by intent to treaty y



Client Information

 Waiver

• IRB variabilityIRB variability

• Unclear whether treatment programs will honor waiver

• Can still examine primary outcomes from CJ and survey data

 Extent, validity of record documentation – reasonable from pilot

 Possible detection bias based on Group (hard to blind RAs)



Self-report data

 Limited information on psychometrics of these reportsp y p

(27)

(28)

Summary



Add

i

t ff k

l d

/

ti

d



Addressing staff knowledge/perceptions and

interorganizational linkages could increase CC

clients’ access to MAT



MATICCE -- multi-site, cluster randomized study



Compares KPI training alone to KPI training plus active

li k

i t

ti

linkage intervention

• Interorganizational Pharmacotherapy Exchange Council (PEC) • Facilitated strategic planning

• Connections coordinator position



Complex project that will attempt to address issues in

• implementation science (interorg. relationships; sustainability)implementation science (interorg. relationships; sustainability) • HSR (structural influences on access, referral, and utilization)

• practical concerns of CJ agencies (facilitating interagency referrals; reducing relapse & arrest)g p )