Introducing NIDA’s Justice Community Opioid Innovation Network (JCOIN)

Tisha R.A. Wiley, Ph.D. and Lori J. Ducharme, Ph.D.
National Institute on Drug Abuse

In the context of addressing the overdose epidemic, the U.S. criminal justice system presents significant opportunities for intervention, challenges for service delivery, and potential for creating essential linkages to community-based services for individuals upon release. More than half of individuals in U.S. jails and prisons meet diagnostic criteria for substance use disorder, and a substantial proportion report regular opioid use (Bronson et al., 2017). Research that can inform and improve service delivery and treatment engagement is critical for this vulnerable population.

In 2019, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative^SM, an ambitious effort to address the opioid crisis through research on the effective management of chronic pain, and the prevention and treatment of opioid misuse and opioid use disorder (OUD). As part of that initiative, the National Institute on Drug Abuse (NIDA), established the Justice Community Opioid Innovation Network (JCOIN) to study approaches to improve OUD treatment services for individuals involved in the justice system.

The delivery of substance use treatment services within correctional settings remains rare, and is challenged by a number of logistical, regulatory, philosophical, and resource hurdles (Fiscella et al., 2018). Continuity of care, both upon incarceration and upon release, is a particular challenge (Joudrey et al., 2019). JCOIN provides an opportunity to test alternative service delivery models to better engage individuals in ongoing treatment, and to support interagency collaborations that can facilitate the transition between criminal-legal and community settings.

JCOIN is a cooperative agreement that supports an array of clinical trials, pilot studies, stakeholder engagements, and dissemination activities. It begins with the perspective that every individual involved in the justice system should have access to evidence-based SUD treatment services, while detained and while in the community. Thirteen large clinical trials are designed to generate evidence about “what works” in these settings and how best to implement those services. Briefly, they can be described in four thematic clusters:

• MOUD Comparative Effectiveness Trials:  Two studies will conduct head-to-head trials of extended-release, injectable medications for opioid use disorder (MOUDs). These trials will help evaluate if these medications are comparable in their effectiveness. One study will compare naltrexone (XR-NTX) to Sublocade, a long-acting buprenorphine formulation that has been approved by the FDA since 2017. The other study will compare XR-NTX to the new Brixadi formulation of long-acting buprenorphine. Both trials initiate medications while the participant is incarcerated, and then provides follow-up services for six months in the community.
• State Policy Rollouts:  Two projects are conducting evaluation and implementation studies as their respective states introduce new policies. One follows a pilot of all three forms of MOUD (methadone, naltrexone, and buprenorphine) in a set of Massachusetts jails, and the other is developing an implementation strategy for the rollout of a new opioid court model in the state of New York.
• Linkage Facilitation:  Seven trials will examine different strategies for linking individuals with community-based treatment services at re-entry, including peer and non-peer navigators, community health workers, recovery case managers, and the use of telehealth services.
• Organizational Collaboration:  Two trials are focused on testing strategies to improve collaboration between justice and treatment agencies. This is a theme that weaves through a number of the JCOIN studies.

The JCOIN clinical trials span a variety of justice settings, including jails and prisons, probation and parole, drug courts, and juvenile justice agencies. All attend to the real-world practicalities of ensuring continuity of care for those transitioning back to the community, and all engage multiple agencies and stakeholders (a minimum of five corrections and treatment agencies per study) to increase their potential scalability and generalizability. A special issue of the Journal of Substance Abuse Treatment, to be released this spring, will include detailed study protocols for each of these clinical trials.

Complementary Research Projects

While the multisite clinical trials are the “engine” for the JCOIN activities, a number of other research projects are designed to complement and extend the lessons from the large trials. These include:

• simulation modeling projects that allow researchers, practitioners, and policy makers to pose “what if” questions and test alternative assumptions about how an intervention or service may play out under different circumstances;
• geospatial modeling projects to better characterize community-level access to treatment;
• repeated public opinion surveys on OUD, justice, and stigma, capturing the broader context of how public opinion changes (or doesn’t) over time;
• a national survey of addiction treatment services delivered within jails across the U.S., to measure change and potential impact over time;
• pilot studies on the use of mobile apps and other teleservices in the context of drug courts;
• studies that test strategies to engage justice-involved populations (in carceral settings and in the community) in COVID-19 testing; and
• economic analyses and practical tools to help agencies make informed decisions about the costs of treatment services.

Building Research Capacity

JCOIN serves as a platform to help expand the research capacity of the field, by providing opportunities for treatment and justice agency staff to learn how to conduct novel research and how to implement evidence-based practices, and by helping established researchers learn how to conduct collaborative research in justice and treatment settings. A suite of complementary activities contributes to this goal.

JCOIN’s Learning Experiences to Advance Practice (LEAP) program is a competitive training program that accepts participants into one- and two-year cohorts where they receive didactic training, mentoring, and hands-on learning experiences to build their research skills and make connections with peers and potential collaborators. 

To support pilot studies and program evaluation activities, JCOIN initiated the JCOIN Research Innovation Grants (JRIG) program. The program, managed by the JCOIN Coordination and Translation Center at George Mason University, provides small grants to support local research activities, and is intentionally “practitioner friendly.” JRIG awards are intended for projects that are time sensitive and may be outside the scope of typical NIDA research grants. Requests for applications open three times per year, with a target of 1-2 awards per round. All applications are reviewed by a committee that includes researchers and practitioners from criminal justice and addiction treatment agencies.

JCOIN will soon make available an online Training and Education Center (JTEC) that will offer an array of short courses related to aspects of addiction treatment, justice systems, and research methods. For example, in partnership with the NIATx team at the University of Wisconsin (who are partners in JCOIN’s Coordination and Translation Center), JTEC will feature a course on implementing the NIATx process in justice systems. Other courses will cover topics including OUD medications, the cascade of care framework, implementation science methods, and techniques for handling missing data.

With additional funding support from the Bureau of Justice Assistance (BJA), JCOIN offers an on-demand training and technical assistance (TTA) program for researchers and practitioners beyond the network itself. The unique niche filled by this service is its focus on research. Individuals conducting research at the intersection of addiction and the justice system can contact the TTA team for assistance identifying appropriate measures, methods, study designs, analytic strategies, or similar questions.

Bridging Research and Practice

JCOIN is designed to facilitate ongoing exchanges between researchers, practitioners, and NIDA leadership. These dynamic interactions keep the network grounded, and input from the practitioner community helps ensure that the research is relevant to the evolving needs of the field. A large and diverse network of treatment and justice practitioners, and stakeholders across a broad range of agencies, both provides real-time insight, and helps disseminate JCOIN findings and products to the practitioner community.

This “bridge” has proven especially valuable during the COVID-19 pandemic, as clinicians and corrections staff have been faced with multiple challenges in balancing staff and patient safety, while continuing to deliver services under rapidly evolving and unprecedented circumstances. As states adopted diverse laws that created both opportunities and challenges, JCOIN’s stakeholders convened to share innovations and ideas with the research teams and NIDA leadership. These discussions inspired additional research. For example, many jails responded to the onset of the pandemic with rapid decarceration, often releasing detainees without adequate discharge plans or linkages to treatment services in the community (many of which had temporarily closed). JCOIN research teams were positioned to identify and track several cohorts into the community, to determine the association between early release, treatment continuity, overdose, and recidivism. Findings will be reported soon.

JCOIN’s stakeholder and practitioner partners will also play an important role in translating findings from the clinical trials into practical lessons and actionable steps for treatment and justice agencies. The network is committed to sharing both the results and optimal strategies for implementing “what works” in routine practice.

To learn more about JCOIN and to access available resources, sign up on the JCOIN Partner Portal at https://JCOINctc.org. For specific questions about the initiative, email NIDA staff at  [email protected]. For more information about the NIH HEAL Initiative, visit https://heal.nih.gov.

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Tisha Wiley, Ph.D., is Chief of the Services Research Branch at NIDA and the Director of the JCOIN initiative. 

Lori Ducharme, Ph.D., is a program official in NIDA’s Services Research Branch and the JCOIN Science Officer.

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References:

Bronson, J., Stroop, J., Zimmer, S., & Berzofsky, M. (2017). Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. Washington, DC: United States Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Fiscella, K., Wakeman, S.E., & Beletsky, L. (2018). Implementing opioid agonist treatment in correctional facilities. JAMA Internal Medicine, 178(9):1153-1154. https://doi.org/10.1001/jamainternmed.2018.3504

Joudrey, P.J., Khan, M.R., Wang, E.A., Scheidell, J.D., Edelman, E.J. McInnes, D.K. & Fox, A.D. (2019). A conceptual model for understanding post-release opioid-related overdose risk. Addiction Science & Clinical Practice, 14(1):17. https://doi.org/10.1186/s13722-019-0145-5