1. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Medication-Assisted Treatment in Community Correctional Environments (MATICCE): An Implementation Study Peter D. Friedmann, MD, MPH Alpert Medical School of Brown University

2. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Financial Disclosures  Alkermes – medication provided for a study of parolees  Pfizer – shareholder (<$1000)

3. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Criminal Justice Addictions Treatment Drug-Involved Offender Services and Systems Issues Public Safety Supervision Monitor illegal behavior Monitor release conditions Re-entry services Health, Public Health Drug use Risk behaviors Recovery Support servicesCoordination B EHAVIORAL C HANGE CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 3

4. CJDATS  Criminal Justice – Drug Abuse Treatment Studies  NIDA-funded multisite research cooperative  10 research centers and CJ partner agencies  Focus is on implementation research Research to understand and improve the processes through which agencies adopt, implement, and sustain quality improvements for treating drug-involved offenders.  Larger cooperative fields multiple study protocols Assessment practices HIV continuum of care Medication-assisted treatment

5. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Background  Despite designation of many drug treatment and other interventions as “evidence-based,” such interventions are slow to be adopted, and are often poorly implemented or difficult to sustain.  One highly effective EBP that is underutilized in criminal justice settings is Medication Assisted Treatment (MAT). CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 5

6. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Current Use of MAT in Potential Partner Agencies (N=50) Jail (n=18) Prison (n=12) P/P (n=12) Drug Court (n=8) Mean % opiate dependent clients30.925.216.549.1 Mean % alcohol dependent clients44.136.934.835.1 % provide/fund Methadone66.783.30.037.5 % provide/fund Buprenorphine5.616.78.312.5 % provide/fund any alcohol MAT77.875.016.737.5 Low current usage = potential high CJDATS impact Friedmann et al., Substance Abuse 2012

7. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Cited Barriers to Use of MAT Jail (n=18) Prison (n=12) P/P (n=12) Drug Court (n=8) State/local regulations prohibiting MATX Security concernsXX MAT offered by community Tx programsXXX Agency favors drug-free Tx over MATXX Lack of qualified staffXX Liability concernsX Cost/reimbursement concernsX Barriers that could be addressed in an implementation study

8. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Willingness to Consider MAT Jail (n=18) Prison (n=12) P/P (n=12) Drug Court (n=8) % open to beginning/expanding Methadone55.683.366.762.5 % open to beginning/expanding Buprenorphine 55.658.383.375.0 % open to beginning/expanding Naltrexone50.058.383.375.0 High feasibility

9. CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ Goals of MATICCE 1.Improve knowledge and perceptions of parole and probation (P/P) staff about community-based MAT. 2.Test effect of organizational linkage intervention (OLI) on interagency coordination between probation/parole agencies and local MAT-providing treatment agencies. 3.Increase the number of probation/parole clients linked with community-based MAT CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 9

10. Two-Part Implementation Strategy  Pilot survey: emphasis on 2 prominent barriers to MAT:  Part 1: Staff Training Addresses: Limited knowledge about MAT effectiveness Inaccurate perceptions of MAT Limited information about local MAT resources “Implementation-as-Usual”  Part 2: Organizational Linkage Intervention identify and resolve barriers to client linkages CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 10

11. Part 1: Staff Training  KPI = Knowledge, Perceptions and Information  Developed with Pacific ATTC Based on Blending materials, TIPs, existing ATTC resources, CJDATS workgroup input  Delivered via local ATTCs  N=618 participants (18 sites) Mainly probation & parole officers Local treatment providers welcome to attend CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 11

12. MATICCE Study Design Baseline Data Collection (all sites) Knowledge, Perception, Information (KPI) Intervention (all sites) RANDOMIZATION Group 1 N=9 Linkage Intervention PEC Strategic Planning Connection Coordinator Group 2 N=9 No Linkage Intervention (KPI only ) End-of-OLI Data Collection (all sites) 6-Month Follow-up Data Collection (all sites)

13. Part 2: Organizational Linkage Intervention (OLI)  OLI based in part on CMHS ACCESS project Adapted 3 components associated with effective organizational integration: Working group of reps from key organizations [PEC] Strategic planning process Boundary spanner [Connections Coordinator] Research Centers provide training and TA around strategic planning / SWOT analysis CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 13

14. Pharmacotherapy Exchange Council (PEC)  Connections Coordinator (1 per site) Person who can best engage both CJ and Tx in implementing changes in procedure/referrals Drug Court, TASC, State/County, Treatment  Co-Chairs: CJ and Treatment (2 per site) Decision-makers for each agency/facility Parole/Probation Director/Supervisor/Manager Treatment program CEO / Clinical Director  Supervisory and Line Staff (up to 8 per site) CJ, TASC, and treatment provider staff  Average = 10 team members per study site CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 14

15. Overview of Phases for the Organizational Linkage Intervention (OLI) Phase Primary Outcome(s) Duration (in weeks) Pre-Phase Local PEC Team is formed and the MATICCE project is introduced 1-2 1.Needs Assessment Assessment PEC completes a Needs Assessment that identifies the relative strengths & weaknesses in the inter- organizational practices associated with MAT 8 2.Strategic Planning Planning PEC develops and adopts a Strategic Plan that identifies goals and objectives for improvements to increase client linkages to MAT 8-12 3.Implementation PEC works in a collaborative manner to implement the objectives and attain the goals identified in their Strategic Plan 16 - 24 4.Follow-Up PEC assesses the relative sustainability of both the process improvement targets achieved and the PEC method for facilitating process improvements 4

16. Strategic Plan Objectives  Additional training for probation/parole staff  Cross-training of probation and treatment staff  Interagency communication  Secure funding to support MAT services  Develop shared guidelines/standards CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 16

17. Demographics CJ Staff (n=309) Tx Staff (n=210) % Bachelor’s degree59.935.1 % Master’s degree29.138.5 Median Years in this field11.010.0 Median Years in this unit/program5.33.3 Median Years in this agency9.74.0 Median Years in this position5.02.8 Median Hours worked per week40.0 % provide supervision (CJ) / counseling (Tx)89.679.0 Median # client contact hours per week20.022.0 Median # clients seen per week2620 Median # on active caseload6540

18. Key Measures – OAMAT and IOR 18 CJ-DATS is funded by NIDA in collaboration with SAMHSA and BJA. 18 Opinions About Medication-Assisted Treatment (OAMAT)Opinions About Medication-Assisted Treatment (OAMAT) knowledge, perceptions, and training experiences related to pharmacotherapies (e.g., methadone, buprenorphine)knowledge, perceptions, and training experiences related to pharmacotherapies (e.g., methadone, buprenorphine) Baseline and 3 mos after KPI trainingBaseline and 3 mos after KPI training Inter-Organizational Relationships (IOR)Inter-Organizational Relationships (IOR) Questions about how participant’s organization coordinates with other agenciesQuestions about how participant’s organization coordinates with other agencies Baseline (and after year-long intervention phase)Baseline (and after year-long intervention phase) Van de Ven & Ferry, 1980

19. Opinions re. MAT: Baseline Not at all Very much Includes n=347 at baseline and 3 mos.

20. Opinions re. MAT: 3-month follow-up Not at all Very much * p<.05 * * * * * * * * *

21. Interorg Relationships  Baseline, end of intervention (in progress)  Organizational Assessment Van de Ven & Ferry, 1980 Agency and Personal Awareness (3 items)  e.g. How well are you personally acquainted with the contact person in this agency? Frequency of Communications (4 items)  e.g. How frequently were personal face-to-face discussions held with people in this agency during the past six months? Quality of Communications (3 items)  When you wanted to communicate with persons in this agency, how much difficulty have you had getting in touch with them? Perceived Effectiveness of Relationship (4 items)  Overall, to what extent are you satisfied with the relationship between your organization and this agency? CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 21

22. Baseline IOR Ratings of Agency and Personal Awareness Measures the extent to which the respondent is familiar with the staff, goals, and clients of the partner program p = 0.05p < 0.001 Very much Not at all

23. Baseline IOR Ratings of Frequency of Communication Measures the number of times during the past six months that different types of communications were transmitted or received p = 0.015p < 0.001 Not at all About every day

24. Baseline IOR Ratings of Quality of Communications Measures respondent assessment of the clarity and ease of sending and receiving messages with the partner program p = 0.02 Very much Not at all

25. Baseline IOR Ratings of Effectiveness of the Relationship Measures the extent to which the respondent judges the working relationship to be committed, worthwhile, productive, satisfying Very much Not at all

26. Baseline IOR Ratings of Quality of Communication: Detailed Differences by Setting Item Corrections (%) Treatment (%) p When you have wanted to communicate with persons in this partner agency, how much difficulty have you had? None at all51.037.10.02 Some40.853.2 Very much8.29.7 Overall, would you characterize your communications with persons in this partner agency during the past six months as high quality? Not at all22.623.1<0.01 Some42.661.2 Very much34.815.7 To what extent are you satisfied overall with the relationship with this partner agency? Not at all15.320.60.11 Some47.652.4 Very much 37.127.0

27. Conclusions  Modest training effects of KPI  Perspective is important Directors perceive stronger IORs than staff report Directors believed staff were more aware of partners and communicated with them more often than staff reported CJ partners perceive stronger IORs than MAT providers Respondents from MAT settings reported less awareness of partner resources, less frequent and lower quality communication MAT providers were more likely to report problems communicating with corrections staff than vice versa CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 27

28. Implications  Directors perceptions of IORs misaligned with realities of front-line staff  Disconnect between corrections’ and MAT providers’ perceptions of the strengths and benefits of their IORs Corrections had more positive views of MAT than treatment providers; they viewed the IORs to be more productive and effective  Will be interesting to see if perceptions converge after OLI  Ongoing evaluation of impact on referral CJ-DATS is funded by NIDA in collaboration with SAMHSA and DOJ 28