Addiction Messenger Feature Article January 2025

Bridging the Gap: How Partnerships Are Transforming Opioid Education for Immigrant Communities

By Sherrie Watkins, LMSW, Opioid Response Network Regional Coordinator, Region 7

Woman crossing stepping stones on a river
Woman crossing stepping stones on a river

Prevention is a cornerstone to addressing substance use disorders, but non-English speakers often face barriers in accessing health information. Inadequate or, in some cases, non-existent culturally and linguistically appropriate services and resources negatively impacts vulnerable communities. This is especially true for immigrant communities and can lead to an inability to access to community resources or healthcare, increased vulnerability, and a sense of isolation. Having access to materials in their native languages ensures that life-saving information is available to communities that might otherwise be excluded.

Driven by a deep connection to his community and a passion for breaking down barriers, one individual took action to ensure health resources were accessible to his community. With unwavering determination and a gift for building partnerships, he collaborated with Opioid Response Network (ORN) Region 7, the Mid-America Addiction Technology Transfer Center (ATTC), and the Addiction Policy Forum (APF) to translate vital educational materials, empowering families with knowledge and tools to protect their loved ones.

Technical assistance centers, such as ORN and ATTC, bring critical expertise in research, data analysis, and evidence-based interventions, while community groups provide invaluable on-the-ground insights and connections to those most affected. Collaboration between these groups is essential to addressing the negative impacts of substance use in the U.S. By working together, they can create culturally relevant strategies, improve resource accessibility, and ensure prevention and treatment efforts reflect the real-world challenges faced by diverse populations.

Sal Valadez, 73, immigrated to the U.S. from Mexico at age 3, and he has resided in St. Louis for many years. Through his work with LiUNA (Laborers’ International Union of North America) and as the Diversity, Outreach, and Marketing Director for the Missouri-Kansas Laborers District Council, Valadez witnessed the disproportionate impact of the opioid crisis on historically underserved ethnic communities. He noticed that Missouri’s opioid overdose and mortality data did not reflect the stories and reality of the crisis at a grassroots level.

“There was an obvious gap of data, and if you don’t have data, you don’t have a response… We’re looking at it from the perspective that the opioid crisis is an epidemic. That means it affects the whole community. But there were gaps in education, prevention resources, and treatment resources,” stated Valadez.
This notable gap in data and available resources was related to members of the Bosnian immigrant community in the St. Louis area. Valadez observed how the impact of overdose deaths on that community was not being widely understood or reported because Bosnian immigrants and their families were classified as “white” in terms of race and “non-Hispanic” in terms of ethnicity. The data did not clearly represent what he was seeing in his community. Valadez felt compelled to act.

Valadez began by collaborating with PreventEd of St. Louis and convening several meetings with community leaders, faith leaders, and clergy to create solutions. These meetings resulted in the coordination of several community opioid education and prevention events aimed at addressing stigma, fear, and mental and behavioral health issues related to substance misuse .

“Collaboration is the essence of what we do,” Valadez said. “It means we share our resources, intellect, knowledge and linkage of and with the grassroots communities, communities who have been historically marginalized. We listen to each other and take action.”

Due to the lack of Bosnian language resources, they used English speaking experts and interpreters. The language assistance provided during these education and prevention events was helpful; however, Valadez knew that more could be done. He reached out to the ORN’s Region 7 team and the APF for technical assistance. Through this partnership, four evidence-based substance use prevention materials were translated from English into Bosnian, marking the first success of Valadez’s efforts!

Valadez formed the Ethnic Community Opioid Response Network of Missouri (ECORN-MO). With the help of board members and a diverse group of individuals, ECORN-MO identified 11 other languages present in the greater St. Louis area for which no prevention materials existed. Following the successful partnership of the Bosnian translations, Valadez reached back out to APF and the Mid-America ATTC to provide further assistance to translate the prevention materials into Arabic, Burmese, Mandarin Chinese, Dari, French, Pashto, Somali, Spanish, Swahili, Tagalog, and Ukrainian.

“This can’t be done without collaboration and partnerships,” Valadez said. “The value in these materials is that the communities can use them. We have to assist the community… Our job is to build relationships based on mutual trust and respect, which will facilitate collaboration on issues of mutual concern… You can’t just take materials to the community without knowing anyone. You need to have people who speak the language and are leaders. And most importantly, we exercise the art of listening.”

The materials were widely disseminated by all partnership members, and to date, website analytics reveal an unexpected outcome. What started as a grassroots initiative to support ethnic communities in St. Louis has reached a global audience, with resources accessed by people from all 50 states and over 200 countries, with 4,560 unique clicks on the various language resources. While the project already demonstrates the powerful impact collaborations between private, federally funded, and grassroots organizations on substance use prevention efforts throughout the U.S. and beyond, Valadez emphasized that the work is far from over. Additional translations will be released in 2025, and efforts to integrate community-level storytelling alongside traditional quantitative metrics in data reporting remain a priority.
“In order to collect those stories, you have to have relationships with those communities,” Valadez said.
The motivation and dedication of one individual’s efforts proves that is possible to bring meaningful change and hope to underserved communities. Effective partnerships foster innovation, bridge gaps in understanding, and amplify the impact of initiatives to combat the devastating effects of opioid misuse.

Sal Valadez can be reached at: [email protected] or 319-383-6200.
For more information and resources on receiving materials or technical assistance contact your regional ATTC Network Center, or The Opioid Response Network.
Watch the 2024 webinar, “Silent No More,” produced in cooperation by the Addiction Policy Forum, Mid-America ATTC, and the Opioid Response Network.

Pharmacy-Based Preventive Services for Opioid Use Disorder: What Support Do Pharmacists Need?

African American woman pharmacist in white lab coat reviewing notes standing in front of shelf fully stocked of medicine

What’s the Question?

More than 90% of Americans live within 5 miles of a community pharmacy, making pharmacists a natural source for opioid-related preventive services, like screening patients for problem use, educating patients about safe medication practices, providing naloxone rescue kits, delivering brief interventions, and making referrals to treatment.

However, little is known about pharmacists’ concerns about opioid-related problems, what prevention-related practices they already engage in, and their commitment or willingness to provide services to people with opioid or other drug use problems. The studies that have been done to date have identified training/education as a primary factor influencing pharmacists’ attitudes toward and skills related to providing opioid-related prevention services. But what other factors might be involved?

How Was This Study Conducted?

For this study, part of the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN-0105), researchers surveyed pharmacists to better understand their concerns about opioid-related problems and preventive services; examine whether their demographics, pharmacy characteristics, and opioid-related education/training played any role in those concerns, and explore other barriers to delivering preventive services.

Who Were the Study Participants?

1146 respondents were recruited from 47 states and DC (AK, ME, and RI were not represented). Approximately 54% of respondents were female, 49% were aged 35-54, 96% were not Hispanic/Latino, 75% were white, 13% were Asian, and 5% were Black. In addition, 32% resided in the Midwest region (South, 30%, Northeast, 20%, West, 17%), 38% practiced in an urban setting (suburban 33%, rural 29%), 64% worked at an independent pharmacy (chain 17%, hospital/clinic 9%, supermarket 7%, other 2%), approximately 53% had more than 10 years of pharmacy experience, and 55% were pharmacy managers/owners.

What Did Researchers Find Out?

Overall, 75.48% of respondents reported having concerns about opioid use problems at their pharmacy practice sites, with 62.04% also reporting concerns about non-opioid drug use problems (illicit and non-opioid drugs).

Pharmacists who asked patients about their opioid use were more likely to report concerns about opioid misuse in their community, suggesting that these conversations might be ideal times for screening or brief intervention. Pharmacists in rural areas also indicated relatively high concerns about opioid and illicit drug misuse and were more likely that pharmacists in urban areas to deliver intervention services, which may be related to the severity of the opioid epidemic in rural areas, as well as the shortage of treatment options in those regions. These findings suggest that rural pharmacists may be more willing than those in urban areas to receive training and deliver services.

As with other studies, education played a key role in pharmacists’ preventive practices and their willingness to engage in such practices. Pharmacists who received 3+ hours of education in the past year were also less likely than pharmacists with no education in the past year to perceive concerns about opioid and illicit drug misuse in their practices, possibly because pharmacists with training are more confident talking to patients about opioids and thus have fewer concerns.

The main barrier to delivering preventive services was time constraints due to high workloads, burnout, or staff shortages. Pharmacists also had concerns about awkward or negative experiences when talking to people about their opioid use, suggesting that communication strategies might be a good component of any training, as well as resources for screening tools, opioid use disorder treatment options, and contacts for addiction treatment programs. Arming pharmacists with accurate information and teaching them how to have these conversations could increase their confidence in delivering these services, making it more likely that they will.

What Are the Implications for the Workforce?

Pharmacists are on the frontlines of the opioid epidemic and could play an extremely important role in keeping people safe and connecting them to services. Having received opioid-related training on screening, intervention, and referral to treatment in the past year was one of the key indicators of willingness to deliver preventive services, something that educators/trainers in the addiction workforce might be able to play a role in.

Additionally, pharmacists noted as a barrier their lack of awareness of local drug treatment programs and a desire to have pamphlets on hand to share with their patients, another way addiction workforce members might be able to get involved.

With the passage of the Mainstream Addiction Treatment (MAT) Act in December 2022, removing the federal legal barrier to pharmacist buprenorphine prescribing, over 10 states are now allowing pharmacists to prescribe controlled substances like buprenorphine under collaborative practice agreements with healthcare providers. Working with pharmacists to increase their willingness to provide such a service and arming them with information and other supports could help make a difference in rates of opioid use disorder and other illicit drug use disorders as well.

Improving First Responders’ Perceptions of Overdose Events and Survivors Through Training Co-Facilitated by Overdose Survivors

CTN Dissemination Library & Northwest ATTC

What’s the Question?

First responders like police, EMTs, and firefighters frequently interact with people who use drugs (PWUD), and, based on how these interactions go, they can either help or harm. First responders have reported negative views toward PWUD and also misinformation related to ways to help them, such as believing that distributing naloxone leads to riskier drug use behaviors (not true). Identifying ways to improve negative beliefs about PWUD and interventions to support them is key to improving interactions between first responders and these communities, which could in turn help reduce rates of both addiction and overdose.

How Was This Study Conducted?

In this project, funded by SAMHSA -- the Connecting the DOTS (Drug Overdose Trust and Safety) Project -- the authors sought to build on the foundation of a prior training project (MO-HOPE) by partnering with the SHIELD (Safety & Health Integration in the Enforcement of Laws on Drugs) Training Initiative to develop an intervention incorporating components based on participant feedback, guidance from subject matter experts, and the emerging success of an occupational wellness approach to professional training.

The curriculum used three core modules: Responder Resilience (reviewing responder stress, burnout, trauma, and mental health), Responder Safety (reviewing bloodborne diseases, overdose recognition, and naloxone administration, as well as fentanyl contact concerns) and empathic communication strategies when responding to an overdose, and Public Safety, reviewing evidence-based treatments and local support services for people with SUD and how first responders can refer to them.

Importantly, the training was delivering using a co-facilitator model, with one trainer being a peer first responder (paramedic for EMS, police officer for law enforcement) and the other a working behavioral health specialist with lived experience of being revived from an overdose by a first responder. This approach was used to model collaboration across sectors, humanize addiction and overdose rescue, and offer insights on how PWUD experience interactions with first responders.

A pre- and post-training survey was used to evaluate this new approach and see if first responders’ beliefs and attitudes toward PWUD and naloxone changed after they attended the training and, if so, did training-associated changes differ by professional population (law enforcement vs. EMS/firefighters).

Who Were the Study Participants?

There were 1,407 participants from 43 agencies within 36 Missouri counties who attended 151 of the trainings between December 2020 and May 2023 who completed the surveys. 53.9% were law enforcement and 46.1% were EMS/firefighters. Most participants identified as white (87%) and men (83%), with the average age 36.31 years. Participants had been in their current field for an average of 11.99 years.

What Did Researchers Find Out?

Though attitudes and beliefs among law enforcement were more negative than among EMS/firefighters both before and after the training, attending the training was associated with improvements in those attitudes and beliefs in both sectors, indicating promise with this new approach. Outside of that, the DOTS/SHIELD training yielded no interaction by profession, with both groups reporting similar improvements. This is likely the result of including profession-specific customization, as well as profession-specific peer trainers.

Including a behavioral health specialist with lived experience helped humanize those on the receiving end of responders’ care and provided a rare glimpse into the positive downstream outcomes of their work.

Using customized training components tailored with local substance use resource information also helped equip first responders with the mechanisms needed to improve survival outcomes, which can not only help the people they serve, but also improve their own attitudes toward PWUD by increasing confidence they would truly be able to help. Connecting people to services can also reduce future overdose events, which can in turn reduce demand on first responders, helping to address compassion fatigue and burnout.

Training components that addressed common misinformation about needlestick injuries and fentanyl exposure also helped officers perceive less risk of threat of potential harm during encounters with PWUD, which in turn could make them more likely to issue referrals to services rather than make arrests.

What Are the Implications for the Workforce?

This study provides great insight into what components make training effective for first responders, and also highlights the value of including both peers and people with lived experience as training facilitators. Tailoring trainings to better inform audiences about resources in their own communities can also increase effectiveness and improve outcomes for attendees. Given the frequency with which first responders encounter people with opioid use disorder or in overdose situations, providing effective training to these groups to reduce stigma and improve interactions with PWUD could make a real difference in the number of overdoses in a given community. Many of the lessons learned by this study may apply to training for other types of service providers as well.

Shannon Roberts

Crystal Jeffers

Kristen Zucht

Susan Garrett

Machine-Learning Algorithm Used to Reveal Factors Impacting Access to MOUD for Unhoused Patients

What’s the Question?

Opioid use disorder continues to be a major public health crisis, with opioids involved in the overwhelming majority of drug overdose deaths in the U.S. in recent years. Medications for opioid use disorder (MOUD), like buprenorphine, naltrexone, and methadone, are effective at reducing overdose deaths, but only a minority of patients are able to access them, and access for patients with unstable housing is even lower.

Many factors influence access to MOUD, but homelessness is a notable barrier because it’s so often associated with limited resources and support, higher rates of physical and psychiatric conditions, and unstable surrounding social environments.

Research on unhoused people with OUD is sparse, however, and in order to improve access to MOUD for people experiencing homelessness, we first need to figure out what factors predict MOUD access and how housing status impacts discrepancies in that access.

How Was This Study Conducted?

In order to dig into factors that predict MOUD access for both housed and unhoused patients, researchers used a “gradient boosted decision tree algorithm” to predict whether a patient admitted with opioid use disorder will receive MOUD. They then examined their model to understand which features/variables were most informative and whether they were associated with treatment or non-treatment.

“Gradient boosted decision tree” is a type of machine learning algorithm that starts by growing a single decision tree from training data (for example: patients aged 35+, not on Medicaid, and going to a facility in California are predicted to receive treatment) and evaluates that decision tree based on actual outcomes. The algorithm then tries to create an improved decision tree based on the errors of the previous tree and repeats this process over and over, eventually learning the patterns in the data that predict treatment. Essentially, it’s creating a more accurate prediction by iteratively learning from past mistakes.

In this study, the gradient boosted decision tree analyzed the 2019 SAMHSA Treatment Episode Data Set for Admissions, which contains information on over 1 million treatment admissions in the U.S.

What Did Researchers Find Out?

The model used in this study was effective in predicting access to MOUD with an accuracy of 85.97%. Overall, only 44.92% of housed patients and 28.56% of unhoused patients had access to MOUD in this study. Results found a high correlation between treatment facility type and MOUD treatment, with unhoused patients being more likely to be admitted to a treatment facility with low rates of MOUD (such as 24-hour hospital inpatient detox, or short-term residential rehab (30 days or less)).

Most unhoused patients entered 24-hour detox facilities, with only 12.57% receiving MOUD, while most housed patients entered ambulatory non-intensive outpatient service settings, where 63% of patients received MOUD. Only 23.56% of unhoused patients ended up at ambulatory non-intensive outpatient services settings, a significant disparity.

Other influential factors included geographic location, referral source, history of prior treatment, and frequency of opioid use.

Based on what they learned from the analysis, the researchers theorize that if unhoused patients instead went to the facilities that housed patients enter at an equal percent (but still received MOUD at the lower unhoused rates), 89.5% of the disparity in MOUD access would be eliminated – quite a significant finding.

What Are the Implications for the Workforce?

Based on this research, MOUD access for unhoused patients appears to be more directly associated with their access to certain service settings rather than how they are treated once they are admitted.

Unhoused patients often seek care service settings where MOUD prescriptions are less likely to be provided (e.g. detox settings). Increasing treatment options for patients and expanding the availability of MOUD to a broader range of settings could help improve outcomes for patients with unstable housing, as could expanded educational outreach to care providers, who have attitudes toward OUD treatment that can vary widely by service setting and geography.

Workforce members should be aware of the disparities in service access between housed and unhoused patients, and consider ways to disrupt these disparities, including interventions to improve education about MOUD for care providers and systems-level changes to MOUD policies in their organizations.

AI Identifies Ketamine as a Potential Treatment for Amphetamine-Type Stimulant Use Disorder

Ketamine

What’s the Question?

Stimulant use in the United States is on the rise, and amphetamine-type stimulants are the second most-used illicit drugs in the world. Along with this rise in stimulant use has been a corresponding increase in overdose deaths related to stimulants, as well as increases in serious and lasting health effects for stimulant users.

All of this has highlighted the need to find effective treatments for stimulant use disorder. To date, there have been no medications approved for treating stimulant use disorder, but finding a medication that would work could make a significant difference not just in treatment outcomes but also in encouraging people to engage in treatment to begin with.

“Drug repurposing,” which identifies new uses for previously approved drugs with established safety profiles, offers a faster and more efficient way to find new treatments for diseases compared to traditional drug development or discovery. But this process can be complex and time-consuming . . . for humans. Artificial intelligence (AI), on the other hand, can process and analyze vast amounts of biomedical data quickly, speeding this process up dramatically.

This study, part of the NIDA Clinical Trials Network study CTN-0114, aimed to put an AI-driven drug discovery framework to work on finding a medication that is already FDA-approved and might work as a treatment for amphetamine-type stimulant use disorder (ATSUD). In a previous study, this same AI-driven framework had discovered that ketamine appeared to improve outcomes for patients with cocaine use disorder – would the AI model also identify ketamine as an effective treatment for ATSUD?

How Was This Study Conducted?

The first step was exploring potential drug candidates for ATSUD. The AI model constructed a knowledge graph, a visualization of relationships between different entities, by integrating multiple biomedical databases and identifying FDA-approved drugs with potential for ATSUD treatment through a systematic analysis of interactions within the knowledge graph.

From there, researchers selected the top 10 ranked drugs as potential candidates. They then reviewed results from clinical trials to see how well these drugs had worked at treating ATSUD. Based on these results, they selected ketamine as their target drug for the rest of the study.

Researchers then analyzed 100 million patient electronic health records (EHR) to look at the association between ketamine and ATSUD remission in clinical cases. Finally, they analyzed the potential mechanisms of action of ketamine in the context of ATSUD, looking at both genetic and molecular factors.

What Did Researchers Find Out?

Patients included in the analyses all had diagnosed ATSUD and had either received anesthesia (n=3663) or been diagnosed with depression (n=4328) (two common reasons patients might be given ketamine). Researchers looked at how many patients who had received ketamine had achieved ATSUD remission within a year.

Ketamine for anesthesia in ATSUD patients was associated with greater ATSUD remission compared with other anesthetics. Similar results were found for ATSUD patients with depression when comparing ketamine with antidepressants, including bupropion/mirtazapine (two medications that have previously shown limited efficacy in treating ATSUD).

Analysis of how ketamine might work to treat ATSUD found that it targets several ATSUD-associated pathways. Ketamine’s interaction with certain genes also highlights its potential to modulate critical neurotransmitter systems, like dopamine and serotonin, which are involved in the reward pathways that contribute to addiction.

In conclusion, the researchers’ AI-driven drug discovery framework identified clinician-prescribed ketamine as a promising treatment for ATSUD.

Future work, including randomized controlled trials, is needed to confirm this finding and to better understand the underlying mechanisms and potential adverse effects.

What Are the Implications for the Workforce?

Stimulant use disorder remains a significant challenge for clinicians, as there are very few evidence-based behavioral interventions and no approved medications. In the U.S., fewer than 20% of people using publicly funded programs for substance use disorders are receiving treatment specifically for stimulant use disorders, even though we know the prevalence of stimulant use disorders is increasing.

There are many barriers to receiving behavioral-type interventions for ATSUD, however, including stigma, lack of awareness that these options exist, insufficient treatment resources in a community, and personal barriers like fear of legal consequences or loss of employment.

Effective medication treatments, however, could remove a lot of these barriers and potentially attract more people to seek care for their ATSUD.

Addiction Messenger Feature Article December 2024

New SAMHSA program strengthens healthcare workforce capacity to treat patients with Alcohol Use Disorder

Ellen Gurung, Specialist, American Society of Addiction Medicine
Stephanie Swanson, Director, American Society of Addiction Medicine

FDA approved Medication for Alcohol Use Disorder

In 2023, 28.9 million (10.2%) people aged 12 or older had a past year alcohol use disorder (AUD) in the United States (SAMHSA, 2024). Left untreated, AUD can have severe medical consequences including alcohol-associated liver disease, cancer, and an increased risk for injuries (CDC, 2021). AUD also leads to premature death and lower overall life expectancy in the United States compared to other high-income countries (CDC, 2021).

Only 7.9% of those with AUD received treatment and less than 2% took a Food and Drug Administration (FDA)-approved medication for AUD (MAUD) (NIAAA, 2024). Despite FDA approval of highly effective, evidence-based MAUD, these medications are substantially underutilized. This treatment gap is partially because customized resources and training are not available for the various members of the workforce treating patients with AUD (Anderson, 2009; Edwards, et al., 2023; Williams, et al., 2018). The lack of education available leads to reduced healthcare professional confidence to provide evidence-based AUD treatment, furthering poor outcomes for patients who receive inadequate care (Anderson, 2009; Edwards, et al., 2023; Williams, et al., 2018).

To address this treatment gap, Providers Clinical Support System – Medications for Alcohol Use Disorder (PCSS-MAUD) provides free, comprehensive training, guidance, and mentoring on the prevention, diagnosis, and treatment of AUD. PCSS-MAUD, a SAMHSA-funded initiative administered by the American Society of Addiction Medicine (ASAM) and its partners, aims to enhance the capacity of multidisciplinary healthcare professionals to treat individuals with AUD, including with the use of FDA-approved MAUD. PCSS-MAUD offers live and self-paced skill-based online modules, webinars, case-based discussions, mentoring, toolkits, consultative services, and other resources for healthcare professionals.
To ensure knowledge and skill gaps are addressed within PCSS-MAUD education, ASAM conducted a literature review and needs assessment, as well as gathered feedback and expertise from multidisciplinary experts from across the country to inform the program curriculum. The curriculum outlines educational offerings that are tailored to different specialties and practice settings aimed at building foundational knowledge to screen, diagnose, and treat AUD using FDA-approved MAUD, as well as how to engage and support diverse populations in treatment. Educational topics include an overview of pharmacologic treatment approaches for AUD, managing alcohol withdrawal in hospitals and ambulatory care, treatment considerations for American Indian/Alaska Natives, and integrating peer support services into treatment.

PCSS-MAUD’s goal within the first year of implementation was to reach 2,000 learners. Within 9 months, PCSS-MAUD engaged 5,812 learners within live and recorded trainings, nearly three times its goal. Not only are healthcare professionals attending and participating in PCSS-MAUD education, but they report high satisfaction rates and anticipate that their work will improve as a result of participating. More than 96% of evaluation respondents reported that participating in a PCSS-MAUD activity will benefit their community and more than 92% indicated that they anticipate an improvement in their ability to work effectively as a result of participating in PCSS-MAUD education. Furthermore, preliminary evaluation data indicates that physicians (MD/DO) were the primary audience within the first year of educational activities (21.9%), followed by nurse practitioners (ARNP) (21.7%). This suggests that PCSS-MAUD’s primary audience can prescribe MAUD for patients with AUD, thus increasing access to evidence-based treatments.

These staggering results suggest both an immense need for high-quality clinician education on alcohol use disorder and the desire of prescribers to learn about and apply evidence-based treatments such as medications for alcohol use disorder to clinical practice. PCSS-MAUD will continue to provide free education that builds skill, knowledge, and confidence to treat AUD in hopes of closing the treatment gap and improving outcomes for the 28.9 million Americans struggling with alcohol use disorder.

For more information and to check out educational trainings and resources, check out pcss-maud.org.

References

  1. Anderson, P. (2009). Overview of interventions to enhance primary-care provider management of patients with substance-use disorders. Drug and alcohol review, 28(5), 567–574. https://doi.org/10.1111/j.1465-3362.2009.00113.x
  2. Centers for Disease Control and Prevention. (2021). Alcohol-Related Disease Impact | CDC. Alcohol and Public Health: Alcohol-Related Disease Impact (ARDI). https://nccd.cdc.gov/DPH_ARDI/default/default.aspx
  3. Edwards, S., Ferguson, T.F., Gasparini, S. et al. Interprofessional education as a potential foundation for future team-based prevention of alcohol use disorder. BMC Med Educ 23, 126 (2023). https://doi.org/10.1186/s12909-023-04100-y
  4. NIAAA. (2024). Understanding Alcohol Use Disorder | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Alcohol’s Effects on Health. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
  5. Substance Abuse and Mental Health Services Administration. (2024). 2023 National Survey on Drug Use and Health (NSDUH) Releases. 2023 National Survey on Drug Use and Health (NSDUH) Releases. https://www.samhsa.gov/data/release/2023-national-survey-drug-use-and-health-nsduh-releases
  6. Williams, E.C., Achtmeyer, C.E., Young, J.P. et al. (2018). Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. J Gen Intern Med, 33, 258–267. https://doi.org/10.1007/s11606-017-4202-z

Funding for this initiative was made possible by cooperative agreement number 1H79TI086771-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Addiction Messenger Feature Article November 2024

Evaluating the Recovery Capital framework in post-prison populations

By Heather Howard, MSW, Ph.D., LICSW (MA,RI), LCSW-QS, Associate Professor, Phyllis & Harvey Sandler School of Social Work, Florida Atlantic University

Man putting hand on shoulder of another man showing compassion.
Peer navigators with similar lived experiences and access to affordable housing were found to be key factors in helping individuals stay on track with their recovery goals and reduce stressors that often lead to a return to use.

These results from our recent study (Howard, et. al, 2024) of a group of individuals involved in the criminal/legal system in South Florida and also having substance use disorders (SUDs) align with existing research showing that combining substance treatment with post-release support lowers recidivism.
Our study explored how stable housing, peer support, and social networks impacted 97 participants over 90 days to evaluate the effectiveness of a recovery program based on a "recovery capital" framework. This approach focuses on the social, personal, and cultural resources that help individuals sustain recovery and avoid reoffending.

Background and Purpose

The U.S. prison population has grown significantly due to drug-related offenses, with many individuals experiencing SUDs. Traditional punitive responses, such as incarceration, have proven ineffective at reducing recidivism. In fact, nearly 77% of people incarcerated for drug offenses are rearrested within five years of release (Alper, et al, 2018). Researchers have identified the need for a more rehabilitative approach, which emphasizes recovery services and harm reduction rather than punishment.
The study used a model called Recovery-Oriented Systems of Care (ROSC), which connects people with community services to improve their quality of life and reduce reliance on the criminal/legal system. The program offered housing vouchers, peer support, care coordination, and financial assistance for essentials like court fees or clothing.

Key Concepts: Recovery Capital and Social Networks

"Recovery capital" refers to the personal, social, and cultural resources that help people maintain recovery (Whitesock, et al, 2018).

The researchers hypothesized that building these forms of capital would improve participants' ability to maintain housing, avoid harm and reduce recidivism.

Methods and Intervention

The study tracked participants' progress through surveys using the Recovery Capital Index (RCI). This tool measures improvements in social and personal well-being over time. Participants received support from peer navigators (individuals with lived/living experience), care coordinators, and housing specialists. The program also provided financial help for rent and other necessities, reducing immediate stress and barriers to recovery.

Participants were recruited from multiple sources, including jails and community reentry programs. Data collection spanned 90 days, with follow-ups at 30-day intervals to monitor personal capital, housing stability, and rearrest rates. The sociodemographic characteristics of the participants were: 80% identified as male and 20 % identified as female. Eighty-one percent of the participants were single, 12 % divorced, and 7 % married. Fifty-three percent of the participants were white, 27 % identified as Black, and 20% identified as Hispanic.

Findings

The results were promising:

Discussion

The study confirms that focusing on recovery capital is an effective strategy for promoting long-term recovery and reducing recidivism. Stable housing and peer support emerged as critical components of success. Having access to affordable housing reduces the stress that often leads to a return to use. Additionally, peer navigators, who share similar lived experiences, foster trust and motivate participants to stay on track with their recovery goals.

The results align with existing research showing that combining substance treatment with post-release support lowers recidivism. For example, earlier studies (Bahora, et al, 2020; Mitchell, et al, 2012) found that individuals who completed both in-prison treatment and aftercare were less likely to have a rearrest than those who received no treatment.

Implications for Policy and Practice

The study highlights the need for policies that prioritize recovery-oriented care over punitive measures. Specifically, the following recommendations emerge:

The findings also suggest the importance of adopting trauma-informed approaches in treatment and reentry programs. Justice professionals and service providers should focus on building safe and supportive environments that foster community connections and personal well-being.

Limitations and Future Research

While the study demonstrates the effectiveness of recovery capital interventions, it has some limitations. The sample size was relatively small, and the study only measured outcomes over 90 days. Future research could explore the long-term impact of recovery capital beyond this initial period. Additionally, expanding similar programs to other regions would help determine whether these findings are applicable in different contexts.

Conclusion

This study supports the idea that recovery is not just about abstaining from substance use but involves building a foundation of personal and social stability. Programs that integrate housing support, peer mentoring, and care coordination offer a practical way to reduce recidivism and promote well-being among justice-involved individuals with SUDs. By shifting from punitive approaches to recovery-oriented care, communities can better support individuals in breaking the cycle of addiction and incarceration.

References

Alper, M., Durose, M., & Markman, J. (2018, May). 2018 update on prisoner recidivism: A 9-year follow-up period (2005-2014). Bureau of Justice Statistics. https://bjs.ojp.gov/library/publications/2018-update-prisoner-recidivism-9-year-follow-period-2005-2014

Bahora, M., Hanafi, S., & Thompson, C. (2020). Evaluating the impact of in-prison therapeutic community treatment and postrelease aftercare on recidivism rates. Journal of Substance Abuse Treatment, 110, 45–53.

Howard, H., Skinner-Osei, P., Mitchell, C., & Jones, E. (2024). Peer work and recovery: a relationship approach. Journal of Social Work Practice in the Addictions, 1–15. https://doi.org/10.1080/1533256X.2024.2308271

Mitchell, O., Wilson, D. B., & MacKenzie, D. L. (2012). The effectiveness of incarceration-based drug treatment on criminal behavior: A systematic review. Journal of Experimental Criminology, 8(4), 451–476.

Whitesock, David & Zhao, Jing & Goettsch, Kristin & Hansen, Jessica. (2018). Validating a Survey for Addiction Wellness: The Recovery Capital Index. South Dakota medicine : the journal of the South Dakota State Medical Association. 71. 202-212.

Black People Receive Lower Doses of Medications for OUD Than White People in Both Real World and Clinical Trial Settings

Person taking medication

What’s the Question?

Methadone and buprenorphine are the standard treatment for opioid use disorder (OUD), and research has found that higher doses can be more effective for some people, especially those who use fentanyl or other synthetic opioids.

However, there are racial and ethnic disparities in access to and quality of treatment for OUD. Compared with Black and Hispanic or Latinx people, white people are more likely to be prescribed medication for OUD (MOUD) and to receive higher doses of it. These disparities have been identified in usual care settings, but it’s less known whether they’re also happening in clinical trials.

Why does that matter? Because results from clinical trials are often what inform treatment recommendations and policies so having the studies accurately represent real-world experiences is important. Most clinical trials use guidance documents to try to apply consistent approaches across all participants, but does bias persist anyway?

How Was This Study Conducted?

To assess these disparities, researchers for this project analyzed the methadone and buprenorphine arms of 3 trials conducted by the NIDA National Drug Treatment Clinical Trials Network (CTN): CTN-0027 (Starting Treatment with Agonist Replacement Therapies, START), CTN-0030 (Prescription Opioid Addiction Treatment Trial, POATS), and CTN-0051 (Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment, X:BOT).

Who Were the Study Subjects?

This study involved 1748 patients (all of whom had been randomized to and initiated treatment with either methadone or buprenorphine):

Black patients had the highest median age with white patients the lowest. White and Hispanic patients were more likely to report a history of psychiatric conditions at baseline than Black patients, and a greater portion of white and Hispanic patients reported moderate or severe withdrawal symptoms at baseline compared to Black patients.

What Did Researchers Find Out?

Analysis revealed that:

What Are the Implications for the Workforce?

In this analysis, white patients generally received higher doses of both buprenorphine and methadone for their opioid use disorder than Black patients, similar to the experiences of Black people in the real world. White people and Hispanic people received similar doses of buprenorphine, but different doses of methadone.

These disparities persisted even though trial staff provided clinical sites with treatment guidance and site clinicians had experience participating in research studies.

Organizations that provide MOUD should consider ways to address these disparities, which can happen without conscious bias. Some examples suggested by the researchers include: educational campaigns to improve awareness of dosing recommendations, training for staff and managers on how to manage bias and mitigate its impact on clinical decision-making, and community-specific interventions that aim to address mistrust of safety and effectiveness of medications for opioid use disorder.

Clinical Supervision Foundations Course Revised

The Clinical Supervision Foundations online course has been revised. This updated version of the course offers certificate of completion, 14 hours of NAADAC continuing education, and 13.5 hours of NASW continuing education.

This 14-hour, self-paced course is designed to introduce the terms, topics, and resources essential to clinical supervision. Revised Edition, September 2024. 

(This course can be taken on its own, but it also serves as a requirement to participate in the ATTC Network's face-to-face training, Clinical Supervision Foundations Part II. HealtheKnowledge is not involved with hosting the in-person portion. You may contact your State’s office or connect to the ATTC Regional Center that serves your state to see if the 2nd in-person piece will be scheduled sometime in your area.)

Check out the course


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Addiction Messenger Feature Article October 2024

In Missouri, a Recovery Friendly School is also a Recovery Friendly Workplace, and a potential model for others to follow in person-centered recovery

By Ann McCauley, director, Missouri Recovery Friendly Workplaces

When a Recovery Friendly School also becomes a Recovery Friendly Workplace, you create an environment that centers the living experience of individuals in recovery, both in and outside the classroom.

On October 24, 2023, the Excel Adult High School in Columbia became the first school in Missouri to earn the Recovery Friendly Workplace (RFW) designation. The Excel Center is an accredited tuition-free high school that gives adults 21 and older the opportunity to earn an actual high school diploma. While earning their diploma, students earn college credits and a variety of industry-recognized certifications to increase their earning potential and employability skills.

Left to right: Reverend James Gray, Ann McCauley (MU Extension), Lawanna Rothman (Excel Center student), Abby Courtney (Career and College Coordinator and teacher at Excel Center), Michelle McDowell (MU Extension), Sawiyyah Chanay (MU Extension)Excel Center Celebration flier– 5 year and RFW Designation
Left to right: Reverend James Gray, Ann McCauley (MU Extension), Lawanna Rothman (Excel Center student), Abby Courtney (Career and College Coordinator and teacher at Excel Center), Michelle McDowell (MU Extension), Sawiyyah Chanay (MU Extension)Excel Center Celebration flier– 5 year and RFW Designation

Recovery Friendly Schools transform student outcomes and employ staff who understand the socioeconomic and environmental factors that affect their academic success. Students who have enrolled in the adult high school have faced barriers such as unemployment, housing insecurity, a lack of transportation, and/or childcare issues.

As a Recovery Friendly Workplace, the school employs life coaches who address the social service needs of each student individually and works to help them overcome the barriers that are preventing them from meeting their academic goals.

Abby Courtney, a teacher and the Career and College Coordinator at the Excel Center, was instrumental in the school’s work to become recovery friendly.

“Becoming a recovery-friendly workplace is a public way to demonstrate what we have been doing all along,” she said. “Through words and deeds, we support our students, showing them that they matter and that we will stick with them in good times and bad. The Excel Center has an inclusive environment we all want to be a part of.”

The Excel Center campus now has additional tools and resources to support students and staff in recovery. Last October, the school completed each of the steps to earn the Recovery Friendly Workplace designation. These included training, planning, and delivering a declaration to staff and students stating the organization’s support for employees and students in recovery.

The Recovery Friendly Workplace designation comes at no cost to businesses. The University of Missouri Extension is funding the initiative thanks to a subaward funded through a Rural Opioids Technical Assistance-Regional (ROTA-R) grant, which is funded by SMHSA. It is the agency’s hope that schools which have been reluctant to give people in recovery a second chance will hear the success stories from the adult high school and decide to become recovery friendly, too.

The Extension received the subaward in partnership with Iowa State University’s Region 7 Networking Center for Rural Opioid Technical Assistance and Training at the Partners in Prevention Science Institute . The project addresses priority gaps and state-identified needs in rural counties in Missouri, Iowa, Kansas, and Nebraska to offer training and technical assistance on the RFW model. The RFW program offers a systems approach to addressing recovery, mental health, and wellbeing and has partnered with agencies, technical assistance providers, and businesses throughout the four-state region, with a goal of expanding the Recovery Friendly Workplace model across the region.

The ROTA-R Recovery Friendly Workplace goals include identifying and prioritizing the needs of rural communities throughout Region 7, increasing the capacity to address opioid and stimulant related training and technical assistance, and increasing access to resources across the continuum of care and diverse audiences. Courtney’s goal is to see all six adult high schools throughout Missouri become designated, and she has been actively reaching out to them.

There are six Adult High Schools located throughout the state: in St. Louis, Columbia, Cape Girardeau, Florissant, Poplar Bluff and Springfield. Since Excel Adult High School became a Recovery Friendly campus, two more schools – one in Springfield, and one in St. Louis – have begun taking the steps to become certified as well.

Each school offers flexible class schedules, supportive relationships with staff, and a life coach who works with students to find solutions to challenges that could hinder their progress. They offer free drop-in childcare centers, transportation assistance, extended hours, and year-round operation, to support students studying to earn a high school diploma while navigating the everyday realities of life.
The mission behind the high school starts at the top and has a rippling effect throughout the building, according to Mike Reynolds, director of the Excel Center.

“We are proud to put the sign on our door that says we welcome all students to join us on the journey to earning their high school diploma,” Reynolds said. “We are proud to support all our students as they work toward changing their lives and the lives of their families in a positive, productive way.”
Kira Ritchie, a person in recovery who graduated with a high school diploma from Excel, expressed the support and gratitude she feels from being a student in a school that adheres to the tenets of a Recovery Friendly Workplace.

“Knowing that my school and the staff took their time to show the community that they are recovery friendly warms my heart,” Ritchie said. “I am thankful for everything this school and teachers have done to help me make it through–in and out of my recovery.”

Another student, Amy Breese, credits her sobriety to the school’s recovery friendly focus.
“The Excel Center is an amazing support system for people who lack confidence. Through their support and love, the staff helps us gain the confidence that addiction took from us,” she said. “By publicly announcing that they are recovery friendly, the Excel Center shows their students that they see us and will not turn their back on us. When I relapsed, they didn’t look down on me. They told me to pick myself up and get moving. They go above and beyond to show us that we matter.”

Because Recovery Friendly Workplaces and Schools address their staff and students’ social determinants of health, they contribute to healthier communities. They foster an awareness of the social and environmental factors that affect the health and wellbeing of all residents, and support community resources that address these issues.

Several months after the Recovery Friendly Workplace designation ceremony at the adult high school, I was invited to attend the next graduation ceremony for students. Two students, a mother and son, shared with me that they would not have succeeded if they hadn’t been attending a school that supported people in recovery, and the mental health needs of students.

Racial and Ethnic Differences in Self-Reported Barriers to Substance Use Treatment

What’s the Question?

Racial disparities in the overdose epidemic have increased in recent years, with Black individuals overtaking white individuals in overdose deaths, rates among Hispanics increasing by 40%, and rates in American Indian people skyrocketing to the highest of all.

However, rates of engagement in treatment for substance use disorder (SUD) differ in the opposite direction for racial minorities, with only 6% of non-Hispanic white and Black participants receiving treatment in the last year and only 2.5% of Asians and 5.4% of Hispanics. Black patients are also less likely to receive medications for alcohol use disorder or opioid use disorder (OUD) than others.

Why are these communities not receiving treatment for their SUDs? This study aimed to find out by asking individuals with SUD themselves what it was that prevented them from receiving care.

How Was This Study Conducted?

Using data from a NIDA Clinical Trials Network study (CTN-0047) conducted in multiple emergency departments (EDs) across the country, researchers looked at both structural and individual barriers to entering SUD treatment by race and ethnicity (broken into 3 categories: non-Hispanic white, non-Hispanic Black, and Hispanic), as well as by severity of drug use.

In the parent study, participants were administered several surveys, responses to which were used in this study. One of the surveys was the Barriers to Treatment Inventory, which breaks its scale items into 7 categories: Absence of problem (e.g., “Don’t think I need treatment”), Privacy concerns (e.g., “Hate personal questions”), Time conflict (e.g. “Have things to do at home”), Admission difficulty (e.g., “Waiting lists for treatment”), Treatment availability (e.g., “Don’t know where to get treatment”), Fear of treatment (e.g., “Bad experience with treatment”), and Negative social support (“Family wants no treatment for me”).

Who Were the Study Participants?

Of the 1285 participants in the parent study with drug severity scores of 3 or higher, 858 completed the BTI at the 3-month follow-up and were included in this study’s sample. Some demographic information about the sample:

What Did Researchers Find Out?

The most commonly cited barrier for all three racial and ethnic groups was Absence of a problem. Over 35% of participants in each group agreed or strongly agreed that they could handle their drug use themselves, and 38%-50% in each group stated that they didn’t need treatment. Those with moderate drug use were more likely to agree with these items than those with more severe drug use, especially if they were white.

Privacy concerns were also widely endorsed, with over 48% of participants in each group agreeing with at least one of the three items in this category. There were some differences between races, with Black participants less likely than white participants to agree that talking in groups was a barrier, and more likely to agree that asking personal questions was a barrier.

Participants with more severe drug use also reported bad previous experiences with treatment that made them afraid to seek out care, as well as a challenges with wait lists when they did try to get help.

Responses varied the most between white and Black participants, with fewer differences between Black and Hispanic participants and almost none between white and Hispanic participants.

What Are the Implications for the Workforce?

This study is one of the first in the U.S. to examine both individual and structural barriers to accessing treatment and examine that association with drug use severity by race and ethnicity. Since the most reported barrier to treatment across all racial and ethnic groups was the perceived absence of a drug problem, increasing availability of screening and counseling, especially using culturally tailored interventions, seems vital.

Participants also reported fear of treatment and privacy concerns as major challenges. To address these barriers, organizations could consider focusing on evidence-based treatments like medication, while reducing requirements that may be invasive or intimidating, like group therapy.

Medication treatments could also help with the structural barriers (lack of access to treatment) reported by people with severe substance use disorders, especially for opioid use disorder. Expanding availability of treatments like buprenorphine for opioid use disorder could improve accessibility, but many treatment programs, including specialty care settings, still do not offer MOUD, further contributing to gaps in care that are even more significant for racial and ethnic minorities.

Overall, these findings demonstrate the heterogeneity of individual and structural barriers within and across groups, which speaks to the importance of increasing the choices of treatment models aligned with the needs of a wider range of the population.

Addiction Messenger Feature Article September 2024

The Latine Community Collaborative: Bridging Research to Practice at the Community Level

By Maxine Henry, MSW, MBA, ATTC Network Coordinating Office, and Shannon L. Roberts, MPH, Peer Recovery Center of Excellence

Bringing evidence-based practices to providers supporting people who use drugs is the cornerstone of the Addiction Technology Transfer Center Network. For more than 30 years, we have positively impacted service delivery models focused on harm reduction, treatment, and recovery for those experiencing substance use challenges.

Over the past three decades the network has been committed to supporting diverse communities across the nation, founded in the unwavering understanding that communities are unique and require nuanced approaches to care. One approach to supporting diverse, underserved, and underrecognized communities involves the careful cultural adaptation to evidence-based practices; an approach that has proven successful with Latine communities1. Another approach has a goal of digging deeper by means of community-defined evidence practice (CDEP), where the people living and working in a particular place have the opportunity to describe and prioritize their challenges, needs, and resources. CDEP ensures meaningful opportunities to leverage community cultural wealth, instead of simply telling a community what is ‘going wrong’ and how they can ‘fix their problems’.

One example of this type of work is the Latine Community Collaborative, a project spanning two years. Comprised of seven SAMSHA-funded training and technical assistance (TTA) centers and more than 30 community members in Puerto Rico, this project exemplifies the ATTC’s collaborative approach to training and technical assistance.

What started with a convening of key collaborators (community organizations, individuals with lived/living experience, and members of the faith community) for two in-person Spanish listening sessions in San Juan, Puerto Rico during the fall of 2022; this group has grown into a well-rounded team that uses CDEP as a framework to amplify the voices of the people most impacted by substance use and the stigma related to these experiences.

In interviews, participants like Dr. Liza San Miguel-Montez and others all spoke about the value the project has brought, particularly in terms of personal growth.

“Our intergenerational group includes a variety of exceptional individuals, recoveries, family members, and specialized mental health professionals, who experience or witness how people with mental health or substance use disorders are stigmatized, rejected, singled out,” Dr. San Miguel Montez said. “Each meeting or gathering is a workshop where we discuss our contributions and realize how much work remains to achieve a culture of openness and compassion for individuals with mental health and substance use disorders.”

Throughout the life of the project the TTA partners have intentionally led with CDEP so that all outcomes and deliverables are of value to the community instead of telling the community what their focus should be. For instance:

After facilitating a year of monthly virtual meetings and a second in-person meeting the community partners have prioritized two specific projects.

ANTI-STIGMA CAMPAIGN
While people who identify as Latine do not experience substance use challenges at higher rates than non-Latine people2, there are significant barriers and challenges which affect access and quality of care3. One of these barriers is the stigma that has long afflicted people who use drugs, which can impact a person’s perception of their drug use and/or need for treatment4.
Cuanto Pesa Tu Estigma is the campaign born out of the painful experiences that stigma perpetuates. Perhaps different from other anti-stigma campaigns, Cuanto Pesa Tu Estigma focuses on what this practice costs those who stigmatize others. The goal is to flip the experience on its head to help people recognize that stigma hurts everyone. In the upcoming months we will expand the campaign to include storytelling via art created by people who use drugs.

For committee member Anna Lopez, working on the Anti-Stigma Committee has been an opportunity to address and challenge the prejudices and stigmas faced by people with mental illness, disabilities, or other differentiating characteristics.

“Participating in the committee has given me the opportunity to educate both at the community and institutional level,” Anna Lopez said. “Developing awareness campaigns and educational programs has been key to changing misperceptions about stigmatized issues and increasing general knowledge. This education is crucial to reducing stigma and fostering empathy in the community.”

PEER WORKFORCE DEVELOPMENT
Peers play a vital role in supporting the health and positive outcomes of people with lived and living experience of substance use and/or mental health challenges. Community partners in Puerto Rico recognized the need to build the capacity of both peers and providers, leading to a comprehensive peer workforce development plan. In collaboration with ASSMCA's Centro de Apoyo Mutuo (CAM), we developed and provided culturally relevant trainings on defining recovery, exploring multiple pathways of recovery, understanding the role of a peer, integrating peer services into existing programming, and supporting the creation of CAM's Code of Ethics for peers. This initiative included a Training of Trainers (ToT), enabling CAM to incorporate the Code of Ethics training into their existing portfolio. Development of the code of ethics is one part of the project CAM’s Claudio Lopez said has been a great pleasure.

“With the help of the project we have been able to expand (the Code of Ethics) outside of Puerto Rico, and developed a workshop regarding the code of ethics,” Claudio Lopez said. “My team and I are more than grateful for all of the support and for accepting that we work hand in hand to provide well-being to society. We hope that the project continues and that you can always count on our support.”

Additionally, we are actively supporting the establishment of a peer certification on the island, which involves translating training curriculum and reviewing it for cultural competency. This multi-faceted plan also includes training for providers and organizations to effectively engage with and integrate peers into their service delivery, as well as ongoing development of additional training and technical assistance opportunities by the Collaborative.

Other key facets of CDEP and community collaboration include a clear understanding of who ‘owns’ the work produced and facilitation of structural competencies so projects are sustainable beyond planning and building phases. In keeping with these principles, we have diligently work with the community partners so they:

Together, the planning and community partners have ensured the Puerto Rican community will continue to have opportunities to build upon the deep knowledge and expertise needed to make real systemic change. The type of change that matters to the community members who deserve equitable and high-quality care.

  1. Domenech Rodríguez D., Baumann M.M. & Schwartz, A.L. Cultural Adaptation of an Evidence Based Intervention: From Theory to Practice in a Latino/a Community Context. Am J Community Psychol 47, 170–186 (2011). https://doi.org/10.1007/s10464-010-9371-4
  2. SAMHSA (2021). 2020 National Survey on Drug Use and Health: Hispanics. https://www.samhsa.gov/data/sites/default/files/reports/rpt37923/2020NSDUHHispanicSlides072522.pdf
  3. Miguel P., Sarah Z., Shannon R., (2018). Understanding barriers to specialty substance abuse treatment among Latinos, Journal of Substance Abuse Treatment, Vol. 94, Pages 1-8,ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2018.08.004.
  4. Pinedo, M. (2020). Help seeking behaviors of Latinos with substance use disorders who perceive a need for treatment: Substance abuse versus mental health treatment services, Journal of Substance Abuse Treatment, Vol 109, Pages 41-45, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2019.11.006.

To learn more about the Latine Community Collaborative and the exciting anti-stigma campaign please visit us online at http://cuantopesatuestigma.org/collaborative/cpte/cuantopesatuestigma.aspx.

Please follow and engage with us on our Latine Community Collaborative Facebook page and on our Latine Community Collaborative Instagram

Delivering Medications for Opioid Use Disorder to the Underserved: Can Pharmacies Help?


What’s the Question?

Access to treatment for opioid use disorder (OUD) is a challenge in rural settings and for communities of color, partly because it can be hard to find providers who are able and willing to prescribe medications for OUD (MOUD).

Pharmacists have been suggested as one way to enhance access to MOUD, as they’re often more available in rural and other underserved communities than primary care physicians or other prescribers.

A key question, however, is whether pharmacies are adequately prepared to distribute medications and other resources to people with OUD. This study, CTN-0124, Assessment and Design of a Cost-Effective Collaborative MOUD Delivery System, aimed to answer that question by examining the potential role of pharmacies in MOUD delivery, looking at what barriers exist, and proposing strategies for improvement.


How Was This Study Conducted?

To address this issue, the study team developed a 9-month “engineering systems analysis,” a problem-solving approach that breaks a system into its individual parts, analyzes how well those parts work together to accomplish their purpose, and creates a proposed design for the future.

To perform this analysis, the study team, made up of 5 systems analysis, as well as experts in pharmacy systems and law, worked together with a regional chain of over 70 independent pharmacies serving rural and underserved communities in Wisconsin and Michigan to assess MOUD distribution processes, regulation, staffing, data systems, training, and reimbursement. They also interviewed 43 subject matter experts (community pharmacists, members of pharmacy associations, and addiction experts), and, finally, looked for opportunities for process improvement.


What Did Researchers Find Out?

When the project began, the study team believed pharmacy roles related to MOUD distribution could easily expand. However, after the study, the team changed its mind, now believing that while this may be possible in large population centers, dramatic expansion in rural and underserved areas will be impractical without significant systemic change.

For pharmacies to take a greater role in MOUD access, the study team says, they need to take advantage of a range of technological innovations to try to overcome all the barriers they and their staff would face.

The team’s specific recommendations, presented in the paper, are based on 9 themes that came up in their analysis: 1) mindset and stigma, 2) simplified and powerful prescription drug monitoring programs (PDMPs), 3) innovations in technology, 4) work simplification, 5) family education and support, 6) integration with other health providers, 7) regulatory reform, 8) reimbursement, and 9) integrated demonstration.


What Are the Implications for the Workforce?

The findings of this system analysis reveal plenty of potential for pharmacies to play a significant role in expanding access to MOUD in underserved communities. However, this expansion will be more complicated than originally expected. Significant systemic changes will be necessary, and challenges like thin profit margins, staff shortages and burn-out, and the stigma surrounding addiction and mental health disorders are all major barriers to widespread adoption.

In light of these findings, the conversation may need to change to one more focused on the crucial role of regulatory, reimbursement, workflow, and technological innovations needed to support pharmacies and their staff in this new role and help them overcome these barriers and challenges.

SAMHSA’s Take-Home Methadone Policies During COVID-19 Did Not Increase Methadone-Involved Mortality

What’s the Question?

In response to the first wave of the COVID-19 pandemic in 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a blanket exception allowing opioid treatment programs (OTPs), with approval from their states, to provide up to 28 days of take-home methadone for clinically stable patients and 14 days for those who were less stable.

The purpose of this exception was to maintain care for people seeking treatment for their opioid use disorder without putting them or clinic staff at increased risk for COVID-19 through regular face-to-face exposure.

There was concern that allowing patients to acquire so much methadone at a time, without the daily supervision provided by clinic visits, might increase their risk for a deadly opioid overdose.

This study aimed to examine the association between this policy change and methadone-involved overdose deaths by comparing states that relaxed take-home dose rules with those that didn’t.


How Was This Study Conducted?

The study author, Harris, obtained data from the Centers for Disease Control and Prevention (CDC) using their online tools. Harris compiled monthly methadone-involved overdose deaths from January 2018 to June 2022 (27 months before the policy change and 27 after) and separated the data into two sets: data from states that permitted extended take-home doses (permitting states) and data from states that did not (non-permitting states). Only states that had OTPs and were consistent with their policies throughout the study period were included.


What Did Researchers Find Out?

Harris examined the two sets of data at three time points: before the policy change in March 2020 (preintervention), at the onset of COVID-19 (April 2020), and after the policy change took effect (postintervention).

Between January 2018 and March 2020 (preintervention), states that subsequently permitted the expanded take-home doses saw a non-significant decline in methadone deaths at a rate of -1.02 per month. For subsequently non-permitting states, the trend line was flat at -0.02 per month. The difference between the groups was -0.99.

In April 2020, just after the onset of COVID-19, both groups saw a similarly sharp increase in methadone-involved deaths: about 50% more than during the preintervention phase, likely related to disruptions due to the pandemic (similar increases were seen for other drug-involved deaths at this same time).

Following the policy change, however, permitting states saw the rate of deaths decrease at -2.31 per month, while non-permitting states saw only a nonsignificant decrease at -0.12 deaths per month.

The difference between the two groups was significant, at -2.19 deaths per month, with states that allowed patients to access extended take-home doses showing greater reductions in monthly mortality.


What Are the Implications for the Workforce?

This study suggests that SAMHSA’s policy change allowing extended take-home doses did not result in an increase in monthly methadone-involved overdose deaths in states that adopted the practice. The trend lines in both sets of states were fairly similar until the policy took effect – then states allowing for extended take-home doses had larger decreases in mortality rates compared to states that did not.

One possible explanation for this decrease is the demeaning experience of having to report every day to an OTP for Black and Hispanic men in particular, who are already marginalized and constantly exposed to systems of surveillance, stigma, and punishment. Allowing for extended take-home doses introduced more of a sense of normalcy and dignity and gave them more control over their own care, all things that can improve adherence and overall well-being.

In February 2024, SAMHSA updated federal methadone regulations to permanently expand these take-home dose flexibilities, although states and local OTPs can still choose whether to participate. However, some states rescinded their policies of permitting extended take-home privileges and trended toward more restrictive dosing. These policy decisions significantly influence patient experiences and could result in less medication adherence and worse outcomes overall. Researchers should explore factors influencing state and OTP dose restrictions and their impacts on patient care, with a special focus on potential disparities in implementation across demographic groups and regions.

Your Guide to Integrating Infectious Disease Testing and Treatment Services in Opioid Treatment Programs

Understanding Substance Use in Older Adults: Critical Prevention and Treatment Factors

By Frederic C. Blow, PhD, Angela Tiberia, MPH, Erin Emery-Tiburcio, PhD, ABPP, E4 Center of Excellence for Behavioral Health Disparities in Aging

Since 2010, population of adults aged 65 and older has experienced a rapid increase, growing by over a third. This surge is primarily due to advances in health benefiting the baby boomer generation, born between 1946 and 1964. By 2034, one in every five Americans is projected to be over 65 years of age.1 The growing aging population has growing healthcare needs. For older adults with substance use disorders (SUDs), this demographic shift has significant implications for the prevention and treatment of substance use disorders.

How bad is the problem?

From a public health perspective, while the actual rates of substance use disorders (SUDs) in adults aged 65 and older may seem relatively low, the sheer size of this population means millions are affected and remain untreated. For instance, in 2020, nearly 3.5 million older adults had a SUD, yet only 245,000 received any form of treatment.2

Older adults have a variety of unique factors that contribute to their increased SUD risk. The baby boomer population came of age during a time of changing attitudes and beliefs around drugs and alcohol, contributing to higher rates of drug and alcohol use when compared to previous generations. Those who experienced substance use issues earlier in life are at a higher risk of recurrence as they age.3; 4 Other factors include changes in the way older adults metabolize drugs and alcohol, making them more susceptible to adverse effects. Chronic pain and other comorbid medical conditions have led to the long-term use of medications such as opioids and benzodiazepines, and substantial increases in misuse and dependence. Older adults are also uniquely susceptible to SUDs due to life transitions (grief due to loss of loved ones), social isolation and loneliness (retirement and loss of purpose, death of a spouse, distance from family), and financial stressors (medical expenses, living on a fixed income), leaving them vulnerable to the unhealthy use of drugs and/or alcohol.5

One of the most influential factors permeating the aforementioned areas is ageism, a form of bias that significantly impacts how older adults are treated. Ageist ideas that older adults don’t use substances contributes to the lack of screening and recognition of SUDs in older adults, as well as the scarcity of age-appropriate treatment options. Ageist ideas that older adults “cannot change” or “do not want to change” their substance use, perpetuate a societal “why bother” mindset, leading to the underdiagnosis and misdiagnosis of SUDs in this population. It is crucial to challenge these stereotypes, as research shows that older adults can and do recover from SUDs. Some research suggests higher recovery rates than their younger counterparts, when provided with proper care and social support.5; 6

Providers across multiple disciplines—including psychologists, physicians, nurses, social workers, peer support specialists, and other mental health professionals—play a crucial role in challenging ageist stereotypes that contribute to the under-recognition and undertreatment of SUDs in older adults. Everyone who interacts with older adults shares the responsibility of fostering a holistic approach to care, ensuring that one of society's most vulnerable populations receives the attention and support they need.

Tips on Screening and Treatment of SUDs in Older Adults

Screening for SUDs in older adults should be done at multiple points: when starting a new medication, in response to new problems or health issues (fall, injury, mental health problems), and as part of their routine annual exam. Key points to keep in mind include:7,8

Key Considerations When Treating Older Adults with Substance Use Disorders
Biological Factors - polypharmacy, age-related metabolic changes
Social Factors - stigma, social isolation due to loss of loved ones, retirement, and mobility limitations
Environmental Factors - access to transportation, comorbid conditions, financial constraints due to fixed income.
Psychological Factors – cognitive impairment for some, mental health

Future Directions

For older adults with SUDs, new and more holistic, adaptive models of care are essential. These models should integrate primary care, geriatric medicine, psychiatry, psychology, pharmacy, social work, and addiction medicine. Additionally, more research is needed to ensure that this important population has the resources they need to thrive both physically and emotionally.

The field would also benefit greatly from increased advocacy to improve comprehensive SUD care for older adults. Although it may seem distant for some, the reality is that all of us are aging. Some of us will need SUD treatment. We all deserve not only respect and value but also the necessary support and equitable access to treatment, relapse prevention, and to thrive.

Resources

Please see the E4 Center website for more information! Specifically, these resources are available:

References

1.         Vespa, J. E., Armstrong, D. M., & Medina, L. (2018). Demographic Turning Points for the United States: Population Projections for 2020 to 2060. US Department of Commerce, Economics and Statistics Administration, US.

2.         Substance Abuse and Mental Health Services Administration. (2021). The 2020 National Survey on Drug Use and Health Detailed Tables.

3.         Barry, K. L., & Blow, F. C. (2016). Drinking over the Lifespan: Focus on Older Adults. Alcohol research: current reviews, 38(1), 115.

4.         Slagsvold, B., & Hansen, T. (2021). The Baby-Boomer Generation: Another Breed of Elderly People? In Generational Tensions and Solidarity within Advanced Welfare States (pp. 153-172). Routledge.

5.         Kuerbis, A., & Sacco, P. (2013). A Review of Existing Treatments for Substance Abuse among the Elderly and Recommendations for Future Directions. Substance abuse: research and treatment, 7, SART. S7865.

6.         Fishman, M., Wenzel, K., Scodes, J., Pavlicova, M., Lee, J. D., Rotrosen, J., & Nunes, E. (2020). Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder. Journal of Adolescent Health, 67(6), 778-785.

7.         Substance Abuse and Mental Health Services Administration. (2020). Treating Substance Use Disorder in Older Adults. Treatment Improvement Protocol (TIP) Series No. 26. 

8.         Blow, F. C., Barry, K. L., Galka, A.M.: Treatment of Substance Use Disorders in Older Adults. In Miller, S.C., Rosenthal, R.N., Levy, S., Saxon, A.J., Tetrault, J.M. & Wakeman, S.E. (Eds.): The ASAM Principles of Addiction Medicine, Seventh Edition. 653-665. (Wolters Kluwer, 2024),

11-Item Substance Use Symptom Checklist Identifies Moderate-Severe Cannabis Use Disorder for Those at Average Risk

What’s the Question?

As cannabis use has increased across the U.S., so has cannabis use disorder (CUD), with estimates of 6.9% of adults meeting criteria for CUD. Patients with mild CUD may not be interested in treatment, but as the severity of their CUD increases, so too might their interest in care. Primary care providers are in a unique position to offer that care, but they need better tools to identify those patients.

This study, part of the NIDA Clinical Trials Network study CTN-0074 (PROUD), evaluated the use of a single-item screen for cannabis (SIS-C) as part of routine primary care, followed by an 11-item Substance Use Symptom Checklist (the “Checklist”) for those who report daily or “almost daily” cannabis use to evaluate for CUD.

While the Checklist has been evaluated psychometrically before, its discriminative validity had not been evaluated and is an important factor in determining its usefulness. (Discriminative validity measures whether two theoretically distinct measures are indeed unrelated, making sure the measure in question is capturing a specific construct.) In this study, the Checklist was compared to the Composite International Diagnostic Interview Substance Abuse Module (CIDI-SAM).

How Was This Study Conducted?

This study was done using electronic health record (EHR) data and a confidential cannabis survey given to Kaiser Permanente Washington primary care patients. Adult patients (equal to or over age 18) were eligible for the survey if they had EHR documentation of a cannabis screen completed as part of routine primary care between January – September 2019 and were randomly sampled to receive the survey (n=5000). The random sample was mailed survey invitation letters, followed by phone reminders, and received $20 for completing the survey, resulting in 1,688 respondents. Of those, 498 reported daily cannabis use on the SIS-C and were included in the final sample.

What Did Researchers Find Out?

Of the 498 study participants, 17% met diagnostic criteria for moderate-severe CUD. The Checklist’s AUROC (“area under the receiver operating characteristic curve” – a metric used to evaluate performance) for moderate-severe CUD was 0.88, meaning the Checklist performed acceptably against the CIDI-SAM. Checklist scores of 1-2 balanced sensitivity and specificity, suggesting meaningful increases in the likelihood of identifying CUD for patients at average risk as Checklist scores increase. Checklist scores of 3 or higher increase the likelihood of moderate-severe CUD to 82% from an average pre-test probability of about 40% among those reporting daily cannabis use.

The Checklist performed best for patients whose prevalence of CUD was average and was less effective for patient subgroups with low or high prevalence of CUD. Given that prevalence of CUD varies by age, sex, and presence of mental health conditions or other SUD, these factors should be taken into account when interpreting Checklist results for individuals.

For example, based on this study’s results, for an 80 year-old woman (low prevalence) or a person with another mental health condition or SUD (high), the Checklist score wouldn’t add meaningful information about the probability of moderate-severe CUD to that provided by the SIS-C alone.

What Are the Implications for the Workforce?

The DSM-5 Substance Use Symptom Checklist is a helpful tool for providers that’s easy to administer and increases the likelihood of correctly identifying moderate-to-severe CUD in patients at average risk. When providers can more accurately screen for CUD, they are better able to have meaningful and helpful conversations with patients about their needs and wants for additional support or care. Though this study reports on the use of the DSM-5 Substance Use Symptom Checklist in primary care settings, this tool is also used in substance use disorder treatment specialty settings as well. Find a copy of the Checklist here.

Need help getting a copy? Email, Meg Brunner, [email protected].

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