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Abstract: Substance use is a public crisis in the U.S. Substance use can be understood as a series of events in the life course, from initiation to mortality. Social Determinants of Health (SDoH) have increasingly been recognized as essential contributors to individuals’ health. This scoping review aims to examine available evidence of SDoH impact on the life course of substance use disorder (SUD). Substance use is a public crisis in the U.S. Substance use can be understood as a series of events in the life course, from initiation to mortality. Social Determinants of Health (SDoH) have increasingly been recognized as essential contributors to individuals’ health. This scoping review, supported by the NIDA CTN Greater Southern California Node, aims to examine available evidence of SDoH impact on the life course of substance use disorder (SUD). Among the 50 studies identified, ten revealed parental monitoring/support and early childhood education as protective factors, while negative peer influences and neighborhood instability were risk factors of substance use initiation. Nineteen articles reported factors associated with escalation in substance use, including unemployment, neighborhood vulnerability, negative peer influence, violence/trauma, and criminal justice system (CJS) involvement. Ten articles suggested that employment, social support, urban living, and low-barrier medication treatment facilitated treatment participation, while stigma and CJS involvement had negative impact on treatment trajectory. Social support and employment could foster progress in recovery and CJS involvement and unstable housing deterred recovery. Four studies suggested that unemployment, unstable housing, CJS involvement, and lack of social support were associated with overdose and mortality. Conclusions: This review underscores the influence of social networks and early life experiences on the life course of SUD. Future SDoH research should investigate overdose and mortality and the impact of broader upstream SDoH on SUD. Interventions addressing these social factors are needed to mitigate their detrimental effects on the trajectories of SUD over the life course.

Abstract:

This presentation reviews the role of Community-Based Participatory Research (CBPR) principles and practices in the implementation of evidence-based and/or community-informed practices. It will include illustrations from current and recent studies of community engagement in identification of barriers and facilitators, co-design of implementation strategies, and conduct of formative evaluations of implementation process and outcomes using the RAPICE (Rapid Assessment Procedures-Informed Community Ethnography) methodology.

Abstract:

This presentation focuses on barriers faced by youth involved in the legal system to access treatment, ongoing efforts going across Indiana to improve training in evidence-based treatment, as well as implementation strategies to improve treatment.

Abstract:

Presenter: Katherine Elkington, PhD, Associate Professor of Medical Psychology (in Psychiatry), Columbia University and New York State Psychiatric Institute

Dr. Elkington describes multi-level barriers to treatment for justice-involved youth, explores the integrated use of the Behavioral Health Care Cascade and ecological theory to conceptualize points of intervention, and describes initial findings from two different interventions that target various aspects of the justice, behavioral health, and family/youth-systems to improve treatment
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Abstract:

Presented by: Marina Toulu-Shams, PhD, Professor, Dept of Psychiatry and Behavioral Sciences, Weill Institute of Infant, Child and Adolescent Psychiatry, Dept of Psychiatry, University of California, San Francisco

Dr. Marina Tolou-Shams, trained as a pediatric and forensic psychologist, is a clinician-scientist. She leads the UCSF Juvenile Justice Behavioral Health lab whose mission is to improve behavioral health outcomes for youth who come into contact with the juvenile justice, child welfare, and foster care systems (https://jjbh.org/). Her NIH-funded research focuses on improving youths’ physical, mental, and emotional health, reducing drug and alcohol use, reducing HIV/STI risk behaviors, and increasing access to evidence-based care with particular emphasis on leveraging technology to achieve these outcomes. One study is a pilot trial of SMS text-messaging platform to engage court-involved youth in substance use or dual diagnosis treatment services. A second developmental study takes a mixed-methods, multi-informant participatory research approach to developing and testing a Foster Care Family Navigator model to improve youth mental health outcomes.

The objectives of the presentation are to:

1. understand the substance use and mental health intervention needs of justice-involved youth;
2. identify barriers to behavioral health care access and engagement; and,
3. discuss ways that technology may hold promise for improving justice-involved youth’s behavioral health and legal outcomes.

Abstract:

Approximately 40% of participants enrolled in CTN studies are women. Yet, women face unique issues when it comes to getting help with substance use disorder. It can be especially difficult for women to receive assistance for substance use disorder during or after pregnancy and when navigating the criminal justice system due to social stigma, legal issues, or other barriers.

The CTN prioritizes enrollment of women and minorities in research studies and recognizes the issues related to their participation. Accordingly, this 60-minute web seminar will consider the unique challenges that women face in the criminal justice system while struggling with substance use disorder. This will help research teams have a better understanding of the experience of women, including those that are pregnant and in the criminal justice system, and help researchers manage study retention and follow-up more effectively.

Presenters: Ank Nijhawan, MD, MPH (UT Southwestern Medical Center, Dallas, TX), Jaimie Meyer, MD, MS, FACP (Yale University, New Haven, CT), Mishka Terplan, MD, MPH, FACOG, DFASAM (Friends Research Institute, Baltimore, MD)

Learning Objectives:

1. Describe the background and treatment of women with substance use in the criminal justice system.
2. Discuss unique challenges of women in the criminal justice system, including considerations for pregnant women.
3. Consider how this impacts research participation for women who use substances and pregnant women who use substances.

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Abstract:

Objective: Sublingual buprenorphine-naloxone and extended-release injection naltrexone are effective treatments, with distinct mechanisms, for opioid use disorder. The authors examined whether patients’ demographic and clinical characteristics were associated with better response to one medication or the other.

Methods: In a multisite 24-week randomized comparative-effectiveness trial of assignment to buprenorphine-naloxone (N=287) compared with extended-release naltrexone (N=283) comprising inpatients planning to initiate medication treatment for opioid use disorder (CTN-0051), 50 demographic and clinical characteristics were examined as moderators of the effect of medication assignment on relapse to regular opioid use and failure to initiate medication. Moderator-by-medication interactions were estimated using logistic regression with correction for multiple testing.

Results: In the intent-to-treat sample, patients who reported being homeless had a lower relapse rate if they were assigned to receive extended-release naltrexone (51.6%) compared with buprenorphine-naloxone (70.4%) (odds ratio=0.45, 95% CI=0.22, 0.90); patients who were not homeless had a higher relapse rate if they were assigned to extended-release naltrexone (70.9%) compared with buprenorphine-naloxone (53.1%) (odds ratio=2.15, 95% CI=1.44, 3.21). In the subsample of patients who initiated medication, the interaction was not significant, with a similar pattern of lower relapse with extended-release naltrexone (41.4%) compared with buprenorphine (68.6%) among homeless patients (odds ratio=0.32, 95% CI=0.15, 0.68) but less difference among those not homeless (extended-release naltrexone, 57.2%; buprenorphine, 52.0%; odds ratio=1.24, 95% CI=0.80, 1.90). For failure to initiate medication, moderators were stated preference for medication (failure was less likely if the patient was assigned to the medication preferred), parole and probation status (fewer failures with extended-release naltrexone for those on parole or probation), and presence of pain and timing of randomization (more failure with extended-release naltrexone for patients endorsing moderate to severe pain and randomized early while still undergoing medically managed withdrawal).

Conclusions: Among patients with opioid use disorder admitted to inpatient treatment, homelessness, parole and probation status, medication preference, and factors likely to influence tolerability of medication initiation may be important in matching patients to buprenorphine or extended-release naltrexone.

Related protocols: CTN-0051

Abstract:

A critical strategy to address the opioid epidemic is increasing access to pharmacotherapy, particularly buprenorphine/naloxone (BUP). BUP is a partial agonist that has a superior safety profile than methadone (MET), a full agonist, in terms of overdose risk. Few studies have compared the long-term outcomes of participants randomized to BUP or MET treatment for opioid use disorder (OUD), however, and differences in treatment retention by medication type may translate into variation in criminal justice outcomes.

This study aimed to compare long-term criminal justice outcomes among opioid dependent individuals randomized to receive buprenorphine or methadone. Five-year follow-up was conducted in 2011-2014 of 303 opioid-dependent participants entering three opioid treatment programs in California in 2006-2009 (as part of CTN-0050, “Starting Treatment with Agonist Replacement Therapy (START)”) and randomized to receive either buprenorphine/naloxone or methadone.

Participants received BUP (n=179) or MET (n=124) for 24 weeks and then were tapered off their treatment over 8 weeks or less or referred for ongoing clinical treatment. Midway through the study, the randomization scheme was switched from 1:1 BUP:MET to 2:1 because of higher drop out in the BUP arm.

Study outcomes included arrests and self-reported incarceration. Predictors included randomization condition (BUP vs. MET), age, gender, race/ethnicity, use of cocaine, drug injection in the 30 days prior to baseline, and study site. Treatment status (BUP, MET, none) during follow-up was included as a time-varying covariate.

There was no significant difference by randomization condition in the proportion arrested (BUP: 55.3%, MET: 54%) or incarcerated (40.9%, 47.3%) during follow-up. Among methadone-randomized individuals, arrest was less likely with methadone treatment (0.50, 0.35-0.72) during follow-up (relative to no treatment) and switching to buprenorphine had a lower likely likelihood of arrest than those receiving no treatment (0.39, 0.18-0.87). Among buprenorphine-randomized individuals, arrest was less likely with receipt of buprenorphine (0.49, 0.33-0.75) during follow-up and switching to methadone had a similar likelihood of arrest as methadone-randomized individuals receiving no treatment. Likelihood of arrest was also negatively associated with older age (0.98, 0.96-1.00); it was positively associated with Hispanic ethnicity (1.63, 1.04-2.56), cocaine use (2.00, 1.33-3.03), injection drug use (2.19, 1.26-3.83), and study site.

Conclusions: In a US sample of people treated for opioid use disorder, continued treatment with either buprenorphine or methadone was associated with a reduction in arrests relative to no treatment. Cocaine use, injection drug use, Hispanic ethnicity, and younger age were associated with higher likelihood of arrest.

Related protocols: CTN-0050

Abstract:

People living with HIV (PLWH) who use substances continue to have shorter life expectancies and worse health outcomes than PLWH who do not use substances. Another important contributor to factors that can affect the health of PLWH who use substances is these individuals’ frequent interactions with the criminal justice system.

This analysis of baseline data from the NIDA Clinical Trials Network CTN-0049 study (Project HOPE) aimed to expand the current literature examining the complex relationships between PLWH who use substances’ substance use behaviors and criminal justice involvement to better inform future studies and program implementation.

Researchers performed latent class analyses (LCA) to identify discrete classes, or clusters, of PLWH based on their past year substance use behaviors and lifetime arrest history. Multinomial logistic regressions were also performed to identify key characteristics associated with class membership. Five classes of substance users were identified (minimal drug users, cocaine users, substantial cocaine/hazardous alcohol users, problem polysubstance users, substantial cocaine/heroin users) as well as 3 classes of arrest history (minimal arrests, non-drug arrests, drug-related arrests).

While several demographic variables such as age and being Black or Hispanic were associated with class membership for some of the latent classes, participation in substance use treatment was the only covariate that was significantly associated with membership in all classes in both substance use and arrest history LCA models.

Conclusions: This analysis supports the utility of latent class analysis in revealing complex patterns of behaviors. The findings are a first step toward better understanding the complex dynamics of substance use and of criminal justice system involvement among PLWH that may be useful in informing the future direction of research studies aiming to examine the complex interactions among substance use, criminal justice involvement, and HIV care. HIV intervention strategies may need to take into consideration such nuanced differences to better inform patient care.

Related protocols: CTN-0049

Abstract:

The acceptability, feasibility, and effectiveness of web-based interventions among criminal justice-involved populations are understudied. This study is a secondary analysis of baseline characteristics associated with criminal justice system (CJS) status as treatment outcome moderators among participants enrolling in a large randomized trial of a web-based psychosocial intervention (Therapeutic Education System [TES]) as part of outpatient addiction treatment.

Using data from CTN-0044 (Web Delivery of Evidence-Based, Psychosocial Treatment for Substance Use Disorders), the authors compared demographic and clinical characteristics, TES participation rates, and the trial’s two co-primary outcomes (end of treatment abstinence and treatment retention) by self-reported CJS status at baseline: 1) CJS-mandated to community treatment (CJS-mandated), 2) CJS-recommended to treatment (CJS-recommended), 3) no CJS treatment mandate (CJS-none).

Results found that CJS-mandated (n=107) and CJS-recommended (n=69) participants differed from CJS-none (n=331) at baseline: CJS-mandated were significantly more likely to be male, screen negative for depression, and score lower for psychological distress and higher on physical health status; CJS-recommended were younger, more likely single, less likely to report no regular Internet use, and to report cannabis as the primary drug problem. Both CJS-involved (CJS-recommended and -mandate) groups were more likely to have been recently incarcerated. Among participants randomized to the TES arm, module completion was similar across the CJS subgroups. A three-way interaction of treatment, baseline abstinence, and CJS status showed no associations with the study’s primary abstinence outcome.

Conclusions: Overall, CJS-involved participants in this study tended to be young, male, and in treatment for a primary cannabis problem. The feasibility and effectiveness of the web-based psychosocial intervention, TES, did not vary by CJS-mandated or CJS-recommended participants compared to CJS-none; CJS-involved participants appeared to experience the usual expected benefits in this large multisite randomized trial. These results should encourage treatment providers, policy makers, and CJS authorities to further consider online psychosocial interventions as viable and appropriate therapeutic approaches in CJS addiction treatment populations.

Related protocols: CTN-0044

Abstract:

A substantial number of substance abusers entering outpatient psychosocial counseling treatment are referred from the criminal justice (CJ) system. This secondary analysis of previously published findings from National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0006 (Motivational Incentives for Enhanced Drug Abuse Recovery: Drug Free Clinics), a large, multi-site trial of a prize-based abstinence incentive intervention, examined the influence of CJ referral on usual care outcomes and response to the incentive procedure. CJ referrals (n=138) were more likely than those not CJ referred (n=277) to provide stimulant negative urine samples whether missing samples were counted as positive or as missing. A significant interaction term was found only for percentage of treatment completers (p=0.27). On that retention variable, and three additional drug use measures, significant incentive effects were confined to participants who entered treatment without referral from the criminal justice system. Nevertheless, there were trends toward better retention and less drug use in CJ referrals who received abstinence incentives as well.

Conclusions: This study suggests that abstinence incentives should be offered as a first priority to stimulant users entering treatment without criminal justice referral. However, incentives can also be considered for use with criminal justice-referred stimulant users, based on the observation that best outcomes were obtained in CJ referrals who also received the abstinence incentive program.

Related protocols: CTN-0006

Abstract:

Despite the established effectiveness of pharmacotherapies for treating opioid use disorders, implementation of medications for addiction treatment (MAT) by specialty treatment programs is limited. This research examined relationships between organizational factors and the program-level implementation of MAT, with attention paid to specific sources of funding, organizational structure, and workforce resources. Face-to-face structured interviews were conducted in 2008 to 2009 with administrators of 154 community-based treatment programs affiliated with the National Institute on Drug Abuse’s Clinical Trials Network; none of these programs exclusively dispensed methadone without offering other levels of care. Implementation of MAT was measured by summing the percentages of opioid patients receiving buprenorphine maintenance, methadone maintenance, and tablet naltrexone. Financial factors included the percentages of revenues received from Medicaid, private insurance, criminal justice, the Federal block grant, state government, and county government. Organizational structure and workforce characteristics were also measured. Implementation of MAT for opioid use disorders was low. Greater reliance on Medicaid was positively associated with implementation after controlling for organizational structure and workforce measures, whereas the association for reliance on criminal justice revenues was negative.

Conclusions: The implementation of MAT for opioid use disorders by specialty addiction treatment programs may be facilitated by Medicaid but may be impeded by reliance on funding from the criminal justice system. These findings point to the need for additional research that considers the impact of organizational dependence on different types of funding on patterns of addiction treatment practice.

Abstract:

Stimulant users who sought treatment in a psychosocial outpatient treatment program participated in a multi-site 12-week randomized controlled trial (n=415) of a prize-based abstinence incentive intervention. Primary study outcomes were published previously (Petry et al., 2005); the present analysis examined the influence of criminal justice referral on treatment retention and stimulant use. In this study, participants were categorized based on study condition (incentives vs. usual care) and whether they were referred to treatment by the criminal justice system. Analyses assessed the separate and interactive effects of these factors on retention and stimulant use. Participants referred from the criminal justice system were more likely to be retained in treatment and to provide stimulant negative urine samples than those not referred from criminal justice. There was a significant interaction of criminal justice referral and incentives on treatment retention. Among voluntary referrals, those receiving abstinence incentives submitted 11.2 negative urines on average vs. 7.8 submitted by those in usual care. Among criminal justice referrals, mean number of negative urines submitted was 12.5 in those who received abstinence incentives vs. 10.3 in usual care.

Conclusions: Abstinence incentives significantly improved outcomes in voluntary but not in criminal justice referred admissions to outpatient treatment, probably due to higher base rates of retention and abstinence in the CJ referrals. Nevertheless, an additive effect of external motivation sources was seen with best outcomes in those exposed to both positive (abstinence incentives) and negative (CJ monitoring and sanctions) motivators and worst outcomes in those with neither source of external motivation.

Abstract:

This presentation, part of a panel at the Society for Clinical Trials annual meeting in 2012 focusing on ethical, regulatory, recruitment issues in vulnerable populations, covers the basic definitions and guidelines for including participants who are considered “prisoners” in substance abuse treatment research. In order to conduct research with prisoners, there are several additional, potentially complex steps that must be undertaken with the researchers’ institutional review board of record. Used as a practical example, National Drug Abuse Treatment Clinical Trials Network protocol CTN-0044, “Web-Delivery of Evidence-Based, Psychosocial Treatment for Substance Use Disorders,” is discussed, as approximately 35% of participants at baseline were either mandated or referred for treatment by the criminal justice system (a handful even wearing monitoring bracelets). In any trial, regardless of whether you have approval to conduct research with prisoners, the study must have procedures in place to determine if a participant is indeed a prisoner. Though this can be straightfoward if the participant is in a detention facility, there are a small number of cases where participants reside in the community but are considered a prisoner under the definition of the Office of Human Research Protections (OHRP). For CTN-0044, this mean the development of a screening procedure that asked a simple question about house arrest and followed-up with additional probes if necessary (for participants in this protocol, even those wearing ankle monitors were not officially considered “prisoners” because while their movements were restricted, they were allowed to come and go of their own accord to the treatment facility). The presentation provides an in-depth look at the issues surrounding research with prisoners, including the importance of including individuals who become incarcerated during a study to reduce bias.

Related protocols: CTN-0044