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BACKGROUND: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. METHOD: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents’ current position at the VHA and their VHA facility’s rate of provision of MOUD among legal-involved veterans. RESULTS: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents’ current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. CONCLUSION: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.

BACKGROUND Compared with non-Veterans, Veterans are at higher risk of experiencing homelessness, which is associated with opioid overdose. OBJECTIVE To understand how homelessness and Veteran status are related to risks of nonfatal and fatal opioid overdose in Massachusetts. DESIGN A cross-sectional study. PARTICIPANTS All residents aged 18 years and older during 2011-2015 in the Massachusetts Department of Public Health's Data Warehouse (Veterans: n=144,263; non-Veterans: n=6,112,340). A total of 40,036 individuals had a record of homelessness, including 1307 Veterans and 38,729 non-Veterans. MAIN MEASURES The main independent variables were homelessness and Veteran status. Outcomes included nonfatal and fatal opioid overdose. RESULTS A higher proportion of Veterans with a record of homelessness were older than 45 years (77% vs. 48%), male (80% vs. 62%), or receiving high-dose opioid therapy (23% vs. 15%) compared with non-Veterans. The rates of nonfatal and fatal opioid overdose in Massachusetts were 85 and 16 per 100,000 residents, respectively. Among individuals with a record of homelessness, these rates increased 31-fold to 2609 and 19-fold to 300 per 100,000 residents. Homelessness and Veteran status were independently associated with higher odds of nonfatal and fatal opioid overdose. There was a significant interaction between homelessness and Veteran status in their effects on risk of fatal overdose. CONCLUSIONS Both homelessness and Veteran status were associated with a higher risk of fatal opioid overdoses. An understanding of health care utilization patterns can help identify treatment access points to improve patient safety among vulnerable individuals both in the Veteran population and among those experiencing homelessness.

Moral Reconation Therapy (MRT), an evidence-based intervention to reduce risk for criminal recidivism among justice-involved adults, was developed and primarily tested in correctional settings. Therefore, a better understanding of the implementation potential of MRT within non-correctional settings is needed. To address this gap in the literature, we evaluated the adoption and sustainment of MRT in the US Veterans Health Administration (VHA) following a national training initiative in fiscal years 2016 and 2017. In February 2019, surveys with 66 of the 78 VHA facilities that participated in the training were used to estimate the prevalence of MRT adoption and sustainment, and qualitative interviews with key informants from 20 facilities were used to identify factors associated with sustainment of MRT groups. Of the 66 facilities surveyed, the majority reported adopting (n = 52; 79%) and sustaining their MRT group until the time of the survey (n = 38; 58%). MRT sustainment was facilitated by strong intra-facility (e.g., between veterans justice and behavioral health services) and inter-agency collaborations (e.g., between VHA and criminal justice system stakeholders), which provided a reliable referral source to MRT groups, external incentives for patient engagement, and sufficient staffing to maintain groups. Additional facilitators of MRT sustainment were adaptations to the content and delivery of MRT for patients and screening of referrals to the groups. The findings provide guidance to clinics and healthcare systems that are seeking to implement MRT with justice-involved patient populations, and inform development of implementation strategies to be formally tested in future trials.

PurposeMany individuals in drug treatment courts (DTCs) have co-occurring mental health and substance use disorders (COD), which can negatively impact treatment engagement, behavioral health and criminal justice outcomes. This paper aims to report results of DTC participants with a COD, who received a 12-month wraparound treatment intervention called MISSION-Criminal Justice (MISSION-CJ) alongside DTC to improve treatment engagement and behavioral health outcomes and reduce reincarcerations.Design/methodology/approachIn this pre-post, single-group pilot, 48 clients enrolled and 81% completed 12-month follow-up assessments (N = 39) and weekly MISSION-CJ fidelity for type and intensity of services delivered. Generalized linear mixed models (GLMMs) were computed with a fixed term for fidelity (e.g. high or low MISSION-CJ), time and a fidelity x time interaction term.FindingsAmong participants, at 12 months, 81% of the participants remained engaged in treatment at study completion, and 89% had high MISSON-CJ fidelity. Clients demonstrated significant reductions from baseline to 12 months in average nights in jail (B = −0.1849511, p < 0.0344), mental health symptoms via the Behavior and Symptom Identification Scale (BASIS) total and subscale scores (B = −0.121613,p< 0.0186) and trauma symptoms on the PTSD Checklist-5 (PCL-5) (B = −0.928791, p < 0.0138). High MISSION-CJ fidelity further improved criminal justice, and behavioral health outcomes.Originality/valueThis was the first reported 12-month MISSION-CJ trial. While feasible to implement, given the design limitations, future research should include a large randomized controlled trial.

Little research has focused on systematically integrating clinical treatment within drug court settings (a type of specialty court, and the most popular type of alternative to incarceration program). This is particularly important for rural drug courts serving participants with both co-occurring mental health and substance use disorders, as these participants often have difficulty engaging in care which is compounded by limited access to treatment services in their communities. This article reports on the preliminary outcomes and policy implications of integrating MISSION-Criminal Justice (MISSION-CJ), a co-occurring mental health and substance use hybrid wraparound treatment and linkage intervention, within a rural Massachusetts drug court. In this open pilot, 73 participants completed an intake and 80% completed a 6-month follow-up assessment. The participants were primarily Caucasian (83.6%), male (57.5%), reported substantial criminal justice histories with an average of 13.93 prior arrests, had extensive substance use and mental health histories, with 71% reporting opioid use, 74% had anxiety, and 68.5% depression at intake. Six-month data indicate statistically significant reductions in nights spent in jail, number of arrests, acute behavioral health symptoms, illicit drug use, as well as an increase in employment and securing stable housing. These data suggest that MISSION-CJ was feasible to implement within a rural drug court. MISSION-CJ is a unique intervention as it offers co-occurring disorders treatment and linkage services that work both within a specialty court setting and in the community. These findings pose critical policy implications as integrated services and a hybrid treatment model are considered to be best practice and may be optimal for rural drug courts where there are limited treatment and service resources.

OBJECTIVES: A variety of patients – including women, older, racial/ethnic minority, rural, homeless, and justice-involved patients – are vulnerable to experiencing poor healthcare access and quality, such as lower quality substance use disorder treatment, than other populations. The current study examined receipt of medications for opioid use disorder by vulnerable populations within Veterans Health Administration (VHA) facilities to determine whether there are patient and facility factors that are associated with disparities in care. METHODS: Using national VHA clinical/administrative data from Fiscal Year 2017, we calculated receipt of medications for opioid use disorder using the American Society for Addiction Medicine quality measure specifications. A mixed-effects logistic regression model tested whether patient vulnerability (i.e., women, older age, racial/ethnic minority, rural residence, homeless, and justice-involved) and facility (e.g., regional location, availability of a methadone clinic) characteristics were associated with medication receipt. RESULTS: Among the 53,568 veterans at VHA facilities diagnosed with opioid use disorder in Fiscal Year 2017, vulnerable populations – including women, older, Black, rural, homeless, and justice-involved veterans – had lower odds of receiving medications for opioid use disorder than their non-vulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with opioid use disorder, but lower odds of receiving medications at facilities in the Southern region compared to the Northeast region of the United States. CONCLUSIONS: Quality improvement efforts targeted at vulnerable populations are needed at the VHA to ensure these groups receive the same quality of substance use disorder treatment as other veterans.

Purpose While serious mental illness (SMI) and substance use disorders (SUD) are common, less research has focused on causal beliefs across conditions. This is an important question when trying to understand the experience of dual diagnosis. The purpose of this paper is to examine how three factors representing causal beliefs (biogenetic, psychosocial or childhood adversity) differ by SMI and SUD. This study also examined how causal beliefs were associated with overall, process and outcome beliefs about recovery. Design/methodology/approach Using Mechanical Turks online panel, 195 research participants from the general public completed measures of recovery – overall, outcome and process – for SMI and SUD. Participants also completed the Causal Beliefs Scale yielding three causal factors for SMI and separately for SUD: biogenetic, psychosocial and childhood adversity. Findings Results indicated participants endorsed biogenetic cause more for SMI and SUD. Moreover, research participants endorsed biogenetic causes more than the other two for SMI. Results also showed the psychosocial cause was positively associated with recovery for SMI. Biogenetic causes were not. Almost none of the causal indicators was significantly associated with recovery for SUD. Originality/value Implications of these findings for future research and public efforts to enhance attitudes about recovery are discussed.

Veterans often need civil legal services, yet little is known about veterans' use and consequences of these services. This study examined veterans seeking legal services at VA-housed legal clinics. Baseline data from 61 clients of two VA-housed legal clinics were used to identify clients' legal needs and psychosocial characteristics. Data collected from 49 (80%) of the same clients two months later were used to address clients' improvement and satisfaction after receiving legal services. At baseline, clients reported a mean of 6.0 (SD = 4.2) legal needs, with the most common being help obtaining VA benefits (87%). Clients represented a vulnerable population in that most had an extensive criminal history (e.g., had been arrested, charged, and incarcerated) and multiple health care needs (had a chronic medical condition, had recently received treatment in an emergency department, and had received psychological treatment due to significant psychological symptoms). At follow-up, clients reported a mean of 4.4 (SD = 3.8) legal needs. Tests to identify changes between baseline and follow-up on legal needs, housing arrangement, psychological symptoms, and substance use yielded few significant results. Most participants did not receive additional help with their legal matters after the baseline appointment. At follow-up, clients reported that few of their legal needs were met but also that they were mostly satisfied with the legal services they received. Findings suggest that because clients may need more intensive legal intervention of longer duration to resolve their legal needs and achieve better housing and health status, VA-housed legal clinics require greater resources and expansion.

OBJECTIVE Recovery from severe mental illnesses (SMI) has been described as an outcome (end state where persons are symptom free) or as a process (despite symptoms, people can pursue life goals). Less clear is whether recovery as a process has credibility in the substance use disorders (SUD) community. We examined how public perceptions and expectations of outcome and process between SMI and SUD differed. A severity effect within SMI and SUD categories was also examined. METHOD Participants (N = 195) read definitions of SMI and SUD and completed an online survey of their agreement on: perceptions of recovery from SMI and SUD as outcome and process, and expectations of recovery as outcome and process. Participants were then given more and less severe SMI (i.e., schizophrenia vs. depression) and SUD (opiate vs. alcohol use) definitions. They then responded to recovery items SMI and SUD conditions with low and high severity. RESULTS For SMI, perceptions and expectations of recovery as process were endorsed more than outcome. Severity effect led to greater increases in perceptions and expectations about recovery as process. Specifically, differences between outcome and process for schizophrenia were significantly larger than for depression. For SUD, expectations of process were significantly lower than outcome ratings. One negative interaction was found for SUD expectations; difference scores for opiate users were smaller than for alcohol. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE We discussed implications for interventions that enhance recovery for people with SMI and SUD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background Opioid overdose (OD) and related deaths have significantly increased in the United States over the last 2 decades. Existing studies have mostly focused on demographic and clinical risk factors in noncritical care settings. Social and behavioral determinants of health (SBDH) are infrequently coded in the electronic health record (EHR) and usually buried in unstructured EHR notes, reflecting possible gaps in clinical care and observational research. Therefore, SBDH often receive less attention despite being important risk factors for OD. Natural language processing (NLP) can alleviate this problem. Objective The objectives of this study were two-fold: First, we examined the usefulness of NLP for SBDH extraction from unstructured EHR text, and second, for intensive care unit (ICU) admissions, we investigated risk factors including SBDH for nonfatal OD. Methods We performed a cross-sectional analysis of admission data from the EHR of patients in the ICU of Beth Israel Deaconess Medical Center between 2001 and 2012. We used patient admission data and International Classification of Diseases, Ninth Revision (ICD-9) diagnoses to extract demographics, nonfatal OD, SBDH, and other clinical variables. In addition to obtaining SBDH information from the ICD codes, an NLP model was developed to extract 6 SBDH variables from EHR notes, namely, housing insecurity, unemployment, social isolation, alcohol use, smoking, and illicit drug use. We adopted a sequential forward selection process to select relevant clinical variables. Multivariable logistic regression analysis was used to evaluate the associations with nonfatal OD, and relative risks were quantified as covariate-adjusted odds ratios (aOR). Results The strongest association with nonfatal OD was found to be drug use disorder (aOR 8.17, 95% CI 5.44-12.27), followed by bipolar disorder (aOR 2.69, 95% CI 1.68-4.29). Among others, major depressive disorder (aOR 2.57, 95% CI 1.12-5.88), being on a Medicaid health insurance program (aOR 2.26, 95% CI 1.43-3.58), history of illicit drug use (aOR 2.09, 95% CI 1.15-3.79), and current use of illicit drugs (aOR 2.06, 95% CI 1.20-3.55) were strongly associated with increased risk of nonfatal OD. Conversely, Blacks (aOR 0.51, 95% CI 0.28-0.94), older age groups (40-64 years: aOR 0.65, 95% CI 0.44-0.96; >64 years: aOR 0.16, 95% CI 0.08-0.34) and those with tobacco use disorder (aOR 0.53, 95% CI 0.32-0.89) or alcohol use disorder (aOR 0.64, 95% CI 0.42-1.00) had decreased risk of nonfatal OD. Moreover, 99.82% of all SBDH information was identified by the NLP model, in contrast to only 0.18% identified by the ICD codes. Conclusions This is the first study to analyze the risk factors for nonfatal OD in an ICU setting using NLP-extracted SBDH from EHR notes. We found several risk factors associated with nonfatal OD including SBDH. SBDH are richly described in EHR notes, supporting the importance of integrating NLP-derived SBDH into OD risk assessment. More studies in ICU settings can help health care systems better understand and respond to the opioid epidemic.

Background Only 7% of individuals with co-occurring mental health and substance use disorder (COD) receive services for both conditions. We implemented and evaluated maintaining independence and sobriety through systems integration, outreach and networking-Veteran's edition (MISSION-Vet), an evidence-based manualized psychosocial intervention for Veterans with CODs. This paper identifies the generative mechanisms that explain “how, for whom, and under what conditions” MISSION-Vet adoption, implementation, and fidelity work when applied in a complex adaptive system with facilitation support. Methods Within two VA healthcare systems (Sites A and B), a hybrid III trial tested facilitation to implement MISSION-Vet. We conducted a two-site case study based on 42 semi-structured consolidated framework for implementation research (CFIR) guided interviews with site leadership, implementers (social workers, peer specialists), and team members (facilitators, site leads). Interviews were coded and CFIR constructs used to generate “Context + Mechanism = Outcome” configurations to understand the conditions of MISSION-Vet adoption, implementation, and fidelity. Results Site A was low, and Site B was high in adoption, implementation, and fidelity. Adoption hesitancy/eagerness (outcome) resulted from the interaction of “external policy” (context) dampening/encouraging a “tension for change” (mechanism). Implementation intensity (outcome) was based on how “peer pressure” or practice culture (context) activated staff “self-efficacy” (mechanism) to engage with MISSION-Vet and appraise its “relative advantage” over current practices (mechanism). Fidelity relied on how “staffing structure and availability” (context) activated/muted “facilitation” (mechanism) to result in strategy and intervention adaptation (outcome). Conclusions We delineated how specific contexts activated certain mechanisms to drive the different stages of implementation of a multi-faceted COD treatment intervention. Trial registration ClinicalTrials.gov, NCT02942979. Plain language abstract Implementation is inherently dynamic and influenced by interdependent factors operating at the individual, organizational, and system levels. This is especially true for complex interventions addressing co-occurring mental health and substance use disorders because such interventions involve multiple treatment modalities delivered simultaneously, in busy practice settings, with challenging populations. This paper pairs consolidated framework for implementation research (CFIR) constructs with a realist evaluation approached to generate configurations important to the adoption, implementation, and adaptation stages of a highly complex intervention addressing the behavioural health and housing needs of a vulnerable population. Each configuration describes how contextual factors trigger mechanisms to generate implementation outcomes and answers “what works for whom, in what circumstances and in what respects, and how?” These findings further our understanding of possible mechanisms of change and push us to be more precise about identifying causal relationships among constructs that contribute to the success of implementing complex interventions. This work also moves us to think theoretically and methodologically in a more dynamic fashion, thereby leading to more responsive implementation practice.

Objective: Despite the growing research on the effectiveness of specialty courts, including drug treatment courts (DTCs) and veterans treatment courts (VTCs), little is known about the unique treat...

This study explored patterns of clinical need among homeless individuals with dual diagnoses, and explored whether certain profiles are characteristic of different demographic groups. Data were drawn from two larger studies conducted with dually diagnosed, homeless individuals (n = 373). Hierarchical cluster analysis identified four subgroups: (1) Clinically least severe, characterized by less frequent psychological symptoms and no history of physical or sexual abuse; (2) Moderate clinical needs, including shorter history of substance use and less frequent psychological symptoms, but symptoms consistent with severe mental illness; (3) Clinically severe, with frequent anxiety, depression, past and recent physical or sexual abuse, and long history of substance use; (4) Least frequent psychological symptoms, but frequent history of physical or sexual abuse and long history of drug use. Women veterans were mostly likely to be classified in cluster 3, and male civilians in cluster 2. Subgroups of homeless individuals with dual diagnoses demonstrated different clusters of clinical needs, having implications for service delivery to the population.

Using data from a social program that provides one year of wraparound services and housing first to chronically homeless adults with mental health and substance abuse problems, this study examines ...

Emotion dysregulation mediates the effects of stress on drinking among individuals with co-occurring emotional and alcohol use disorders (AUD). The current study examined the effects of cognitive reappraisal (CR), an adaptive emotion regulation strategy, on mechanisms that contribute to drinking (alcohol craving, inhibitory control) among 50 women veterans. In session one, participants were randomized to one of two 50-min “microinterventions”, either to learn a CR coping strategy or receive non-therapeutic psychoeducation control. In session two, all participants underwent a personalized stress induction, after which women in the experimental condition were instructed to use CR to reduce stress, while those in the control group were instructed to sit quietly. Craving and inhibitory control were measured at post-stress induction and after using CR/sitting quietly. Moderating effects of AUD, depression, and PTSD severity were assessed. Craving and inhibitory control improved among women in both conditions (CR or sitting quietly), with no main effect of condition. Condition by AUD severity had a significant interaction effect (b = 0.018, p = .013), whereby women with more severe AUD had greater decreases in craving after sitting quietly, and women with less severe AUD had greater decreases in craving after CR. The opposite pattern was observed for inhibitory control (b = 6.45, p = .004), with women with less severe AUD having greater decreases in inhibitory control after sitting quietly, and women with more severe AUD having greater decreases in inhibitory control after CR. Results highlight CR's immediate effects on alcohol-related outcomes and the important role of symptom severity.

Vaping, the inhalation of a nicotine or tetrahydrocannabinol (THC), cannabidiol (CBD), or non-drug infused solution delivered by vaping devices, is a growing phenomenon across many segments of the US population. Complications associated with vaping are newly emerging and relatively unstudied; little guidance exists on how clinicians may best elicit information related to vaping practices and associated medical problems. This publication, therefore, provides physicians and other treatment clinicians with direction for obtaining the medical history that can guide clinical decision-making for patients at risk for adverse effects associated with vaping.

Objectives This study tested the impacts of peer specialists on housing stability, substance abuse, and mental health status for previously homeless Veterans with cooccurring mental health issues and substance abuse. Methods Veterans living in the US Housing and Urban Development-Veterans Administration Supported Housing (HUD-VASH) program were randomized to peer specialist services that worked independently from HUD-VASH case managers (ie, not part of a case manager/peer specialist dyad) and to treatment as usual that included case management services. Peer specialist services were community-based, using a structured curriculum for recovery with up to 40 weekly sessions. Standardized self-report measures were collected at 3 timepoints. The intent-to-treat analysis tested treatment effects using a generalized additive mixed-effects model that allows for different nonlinear relationships between outcomes and time for treatment and control groups. A secondary analysis was conducted for Veterans who received services from peer specialists that were adherent to the intervention protocol. Results Treated Veterans did not spend more days in housing compared with control Veterans during any part of the study at the 95% level of confidence. Veterans assigned to protocol adherent peer specialists showed greater housing stability between about 400 and 800 days postbaseline. Neither analysis detected significant effects for the behavioral health measures. Conclusions Some impact of peer specialist services was found for housing stability but not for behavioral health problems. Future studies may need more sensitive measures for early steps in recovery and may need longer time frames to effectively impact this highly challenged population.

Legal clinics housed by the Department of Veterans Affairs (VA) help veterans eliminate service access barriers. In this survey of 95 VA-housed legal clinics (70% of clinics), clients' legal problems were mainly estate planning, family, obtaining VA benefits, and housing (14-17% of clients). Most clinics rarely interacted with VA health care providers, did not have access to clients' VA health care records, and did not track clients' VA health care access (58-81% of clinics); 32% did not have dedicated and adequate space. Most clinic staff members were unpaid. Survey findings-that most VA-housed legal clinics do not interact with VA health care or directly address clients' mental health and substance use needs, and lack funds to serve fully all veterans seeking services-suggest that VA and community agencies should enact policies that expand and fund veterans' legal services and health system interactions to address health inequities and improve health outcomes.

Among individuals experiencing chronic homelessness, there is a high rate of co-occurring mental health and substance use, which has traditionally been addressed through the delivery of permanent supportive housing along with substance use and mental health services. However, this population often has difficulty engaging in treatment for co-occurring disorders, which can result in exacerbation of symptoms and housing loss. Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION) is a co-occurring mental health and substance use wraparound approach that was pilot-tested alongside Permanent Supportive Housing (PSH) to improve treatment access and engagement. This pilot was part of a state plan to end homelessness in the Boston metro area.This open pilot study enrolled 136 individuals who were chronically homeless and offered one year of MISSION along with PSH. Program participants also received baseline and 6- and 12-month follow-up assessments.At one-year follow-up, 82.4% of the program participants were housed in PSH. However, due to limited affordable housing in the Boston metro area, it took on average 6.20 months to house the program participants. Furthermore, while MISSION was feasible to implement alongside PSH, fidelity to the MISSION model was lower than expected. This pilot also examined the role of housing status on clinical outcomes and found that the program participants who were housed at the time of discharge displayed a statistically significant improvement in emergency room visits for mental health complaints, the Psychosis subscale of the Behavior and Symptom Identification Scale (BASIS-32), illegal drug use, and pharmacotherapy treatment.This pilot study demonstrated that systematically integrating PSH and MISSION can improve access and engagement in care, housing retention, and mental health outcomes. Despite the preliminary success and while taking into account the limitations of the open single-group pre/post design, this study also identified the lack of affordable housing as a potential barrier to placement as well as the critical role of housing for improved clinical outcomes. Randomized controlled trials are needed to test MISSION with PSH as well as perhaps PSH with and without MISSION to tease apart the effects of integrating both approaches simultaneously.

Aims To determine the accuracy of a wearable sensor to detect and differentiate episodes of self-reported craving and stress in individuals with substance use disorders, and to assess acceptability, barriers, and facilitators to sensor-based monitoring in this population. Methods This was an observational mixed methods pilot study. Adults enrolled in an outpatient treatment program for a substance use disorder wore a non-invasive wrist-mounted sensor for four days and self-reported episodes of stress and craving. Continuous physiologic data (accelerometry, skin conductance, skin temperature, and heart rate) were extracted from the sensors and analyzed via various machine learning algorithms. Semi-structured interviews were conducted upon study completion, and thematic analysis was conducted on qualitative data from semi-structured interviews. Results Thirty individuals completed the protocol, and 43 % (N = 13) were female. A total of 41 craving and 104 stress events were analyzed. The differentiation accuracies of the top performing models were as follows: stress vs. non-stress states 74.5 % (AUC 0.82), craving vs. no-craving 75.7 % (AUC 0.82), and craving vs. stress 76.8 % (AUC 0.8). Overall participant perception was positive, and acceptability was high. Emergent themes from the exit interviews included a perception of connectedness and increased mindfulness related to wearing the sensor, both of which were reported as helpful to recovery. Barriers to engagement included interference with other daily wear items, and perceived stigma. Conclusions Wearable sensors can be used to objectively differentiate episodes of craving and stress, and individuals in recovery from substance use disorder are accepting of continuous monitoring with these devices.

Little research has focused on systematically integrating clinical treatment within existing drug court procedures. This could be particularly useful for clients with substance use disorders, who comprise those on court dockets and often have co-existing mental health issues. This article reports on the preliminary outcomes of integrating MISSION-Criminal Justice (MISSION-CJ), a co-occurring mental health and substance use wraparound intervention, within two Massachusetts drug courts. In this open pilot, clients completed intake and 6-month follow-up assessments. The participants were primarily Caucasian (86%), male (82%), had at least 2 prior arrests, and received outpatient treatment for mental health (54%), alcohol use (51%), or drug use (88%) prior to enrolling in MISSION-CJ. Six-month follow-up data suggested that participants showed statistically significant reductions in average number of nights spent in jail, alcohol use, and drug use, as well as an increase in full time employment.

Moral Reconation Therapy (MRT) is a cognitive-behavioral intervention aimed at reducing risk for criminal recidivism by restructuring antisocial attitudes and cognitions (i.e., “criminogenic thinking”). MRT has empirical support for reducing risk for criminal recidivism among civilian offenders. Recently, a version of MRT was developed for military veterans; however, no randomized controlled trials (RCT) have been conducted with the veteran-specific protocol, and the effectiveness and implementation potential of MRT outside of correctional settings has not been established. Using a Hybrid Type 1 RCT design, this study will test the effectiveness of MRT to reduce risk for criminal recidivism and improve health-related outcomes among justice-involved veterans entering mental health residential treatment at three US Veterans Health Administration (VHA) Medical Centers. Upon admission to the treatment program, justice-involved veterans will complete a baseline assessment, be randomized to usual care (UC) or UC + MRT, and be followed 6 and 12 months post-baseline. A process evaluation will also be conducted to identify barriers and facilitators to implementation of MRT in residential treatment. The primary aim of this study is to evaluate the effectiveness of MRT with justice-involved veterans. If MRT proves effective in this trial, the findings can provide large healthcare systems that serve veterans with an evidence-based intervention for addressing criminogenic thinking among justice-involved adults, as well as guidance on how to facilitate future implementation of MRT in non-correctional settings. This trial is funded by the VA Health Services Research & Development Program (IIR 14–081) and is registered with ClinicalTrials.gov (ID: NCT02524171 ).

PURPOSE OF REVIEW: The goal of this review is to highlight recent research in mHealth based approaches to the detection and treatment of substance use disorders in adolescents and young adults. RECENT FINDINGS: The main methods for mHealth based detection include mobile phone based self-report tools, GPS tracking, and wearable sensors. Wearables can be used to detect physiologic changes (e.g., heart rate, electrodermal activity) or biochemical contents of analytes (i.e. alcohol in sweat) with reasonable accuracy, but larger studies are needed. Detection methods have been combined with interventions based on mindfulness, education, incentives/goals and motivation. Few studies have focused specifically on the young adult population, although those that did indicate high rates of utilization and acceptance. SUMMARY: Research that explores the pairing of advanced detection methods such as wearables with real time intervention strategies is crucial to realizing the full potential of mHealth in this population.

SummaryMental illness recovery has been described as an outcome (symptom free) or process (symptom management) where peer supporters are essential. Whereas, substance use disorder recovery endorses outcome alone: achieving recovery once abstinent. Peer supporters with an abstinence agenda use confrontation for those in denial. Herein, we unpack this distinction.Declaration of interestsNone.

Background Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). Methods Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28–61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. Results The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. Conclusions Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

Objective Although drug treatment courts (DTCs) have demonstrated positive outcomes, participants with co-occurring mental health and substance use disorders (CODs) are a high-risk group that often struggle with treatment engagement not previously examined. This pilot study fills this gap by looking at six-month behavioral health and criminal justice outcomes among a hard to engage DTC COD participant sample in two Massachusetts DTCs receiving a wraparound-treatment (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice - MISSION-CJ). Methods Participants were evaluated at baseline and at six-month follow-up. Bivariate analyses examined baseline differences between clients with higher versus low engagement were examined. A mixed analysis of variance (ANOVA) for repeated measures with time as the within subject factor, and level of engagement as the between subject factor was performed for criminal justice (CJ) and behavioral health outcomes. Results Participants were primarily male (86.6%), White (90.6%), living in unstable housing (86.2%), had an average of 18.94 years of criminal justice involvement, had an average of 15.49 years of regular illicit substance use, and mild mental health symptoms as measured by the BASIS-32 average total score (0.51), with no statistically significant differences at baseline from bivariate analyses. Mixed ANOVA results demonstrated significant effect time of time in MISSION-CJ on reducing nights in jail (p = 0.0266), opioid use (p = 0.0013), and mental health symptom (p = 0.0349). Additional improvements in nights in jail p = 0.0139), illicit substance use (p = 0.0358), and opioid use (p = 0.0013), were observed for clients that had high engagement in MISSION-CJ. Conclusions Wraparound services, such as MISSION-CJ, alongside DTC programming for a chronic relapsing DTC population can improve engagement in treatment and CJ and behavioral health outcomes. Future research is needed with MISSION-CJ that includes a randomized trial and a larger sample.

Introduction Veterans with mental health disorders smoke at high rates, but encounter low rates of tobacco treatment. We sought to understand barriers and facilitators to treating tobacco use in VA mental health clinics. Methods This qualitative study was part of a trial evaluating a telephone care coordination program for smokers using mental health services at six VA facilities. We conducted semi-structured interviews with 14 staff: 12 mental health clinic staff working at the parent study's intervention sites (n = 6 psychiatrists, three psychologists, two social workers, one NP), as well as one psychiatrist and one psychologist on the VA's national tobacco advisory committee. Interviews were transcribed and inductively coded to identify themes. Results Five "barriers" themes emerged: (1) competing priorities, (2) patient challenges/resistance, (3) complex staffing/challenging cross-discipline coordination, (4) mixed perceptions about whether tobacco is a mental health care responsibility, and (5) limited staff training/comfort in treating tobacco. Five "facilitators" themes emerged: (1) reminding mental health staff about tobacco, (2) staff belief in the importance of addressing tobacco, (3) designating a cessation medication prescriber, (4) linking tobacco to mental health outcomes and norms, and (5) limiting mental health staff burden. Conclusions VA mental health staff struggle with knowing that tobacco use is important, but they face competing priorities, encounter patient resistance, are conflicted on their role in addressing tobacco, and lack tobacco training. They suggested strategies at multiple levels that would help overcome those barriers that can be used to design interventions that improve tobacco treatment delivery for mental health patients. Implications This study builds upon the existing literature on the high rates of smoking, but low rates of treatment, in people with mental health diagnoses. This study is one of the few qualitative evaluations of mental health clinic staff perceptions of barriers and facilitators to treating tobacco. The study results provide a multi-level framework for developing strategies to improve the implementation of tobacco treatment programs in mental health clinics.

Background Homeless veterans often have multiple health care and psychosocial needs, including assistance with access to housing and health care, as well as support for ongoing treatment engagement. The Department of Veterans Affairs (VA) developed specialized Homeless Patient Alignment Care Teams (HPACT) with the goal of offering an integrated, “one-stop program” to address housing and health care needs of homeless veterans. However, while 70% of HPACT’s veteran enrollees have co-occurring mental health and substance use disorders, HPACT does not have a uniform, embedded treatment protocol for this subpopulation. One wraparound intervention designed to address the needs of homeless veterans with co-occurring mental health and substance use disorders which is suitable to be integrated into HPACT clinic sites is the evidence-based practice called Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Veterans Edition, or MISSION-Vet. Despite the promise of MISSION-Vet within HPACT clinics, implementation of an evidence-based intervention within a busy program like HPACT can be difficult. The current study is being undertaken to identify an appropriate implementation strategy for MISSION-Vet within HPACT. The study will test the implementation platform called Facilitation and compared to implementation as usual (IU). The aims of this study are as follows: (1) Compare the extent to which IU or Facilitation strategies achieve fidelity to the MISSION-Vet intervention as delivered by HPACT homeless provider staff. (2) Compare the effects of Facilitation and IU strategies on the National HPACT Performance Measures. (3) Compare the effects of IU and Facilitation on the permanent housing status. (4) Identify and describe key stakeholders’ (patients, providers, staff) experiences with, and perspectives on, the barriers to, and facilitators of implementing MISSION. Design Type III Hybrid modified stepped wedge implementation comparing IU to Facilitation across seven HPACT teams in three sites in the greater Los Angeles VA system. This is a cluster randomized trial. Discussion Integrating MISSION-Vet within HPACT has the potential to improve the health of thousands of veterans, but it is crucial to implement the intervention appropriately in order for it to succeed. The lessons learned in this protocol could assist with a larger roll-out of MISSION within HPACT. This protocol is registered with clinicaltrials.gov and was assigned the number NCT 02942979.

Background and Objectives Although advocates and providers identify stigma as a major factor in confounding the recovery of people with SUDs, research on addiction stigma is lacking, especially when compared to the substantive literature examining the stigma of mental illness. Methods A review of key studies from the stigma literature that yielded empirically supported concepts and methods from the mental health arena was contrasted with the much smaller and mostly descriptive findings from the addiction field. Results Integration of this information led to Part I of this two part paper, development of a research paradigm seeking to understand phenomena of addiction stigma (eg, stereotypes, prejudice, and discrimination) and its different types (public, self, and label avoidance). Conclusions and Scientific Significance In Part II paper (American Journal of Addictions, Vol xx, pages xxx–xxx, this issue), we address how this literature informs a research program meant to develop and evaluate and stigma strategies (eg, education, contact, and protest). Both papers end with recommendations for next steps to jumpstart the addiction stigma portfolio. Here in Part I, we offer one possible list of key research issues for studies attempting to describe or explain addiction stigma. (Am J Addict 2016;XX:1–8)

Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

Objective: Peer services have been identified as a key agent in promoting recovery (both as an outcome and as a process) for people with co-occurring disorders. We attempt to make sense of this con...

Veterans in treatment for substance use disorders (SUD) often report past criminal offending. However, the rate of criminal recidivism in this population is unknown. Further, prior research in veterans has not examined personality factors as predictors of recidivism, despite the prominence of such factors in leading models of recidivism risk management. We examined these issues in a secondary data analysis of 197 military veterans with a history of criminal offending who were enrolled in an SUD residential treatment program. Participants were interviewed using several measurement instruments at treatment entry, one month into treatment, treatment discharge, and 12 months post-discharge. Most veterans (94%) had a history of multiple charges, and 53% had recent involvement in the criminal justice system at the time of treatment entry. In the 12 months post-discharge, 22% reported reoffending. In addition, 30% of patients who had been recently involved in the criminal justice system at treatment entry reoffended during follow-up. Higher friend relationship quality (OR = 2.32, 95% CI [1.03, 5.21]) at treatment entry and higher staff ratings of patients’ relationship quality with other residents during treatment (OR = 2.76, 95% CI [1.40, 5.41]) predicted lower odds of recidivism post-discharge. After accounting for these factors, smaller reductions during treatment in the personality trait of Negative Emotionality predicted an increased risk for criminal recidivism post-discharge (OR = 1.13, 95% CI [1.01, 1.26]). Results support augmenting the curriculum of SUD programs for veterans with services aimed at reducing risk for criminal recidivism, with a focus on interventions that directly target patients’ social support networks and tendencies towards negative emotionality.

Veterans treatment courts (VTCs) have expanded dramatically despite their limited empirical base. This pilot study examined MISSION-Criminal Justice (CJ), a co-occurring disorders wraparound intervention, delivered alongside two VTCs. Baseline data from 26 male veterans enrolled in two VTCs and MISSION-CJ, and 6-month follow-up data for 18 of the 26 veterans, are presented. Veterans on average were 37.5 years old, 85% Caucasian, had significant histories of criminal justice involvement (14.3 lifetime arrests), had an average of 14.7 years of alcohol use and 9.3 years of illicit drug use, and roughly three-quarters reported mental health symptomatology. At 6-month follow-up, veterans demonstrated improvements in behavioral health, substance use, and criminal justice outcomes. This study demonstrated promising preliminary outcomes of MISSION-CJ in VTCs. A randomized controlled trial is a critical next step to examine whether these outcomes remain consistent with a more rigorous design.

This pilot study examined whether substance use or mental illness was more stigmatizing among individuals with co-occurring mental health and substance abuse problems.This study included 48 individuals with co-occurring substance use and mental health problems enrolled in a Substance Abuse and Mental Health Services funded treatment program. Subjects received a baseline assessment that included addiction, mental health, and stigma measures.The sample consisted primarily of White males with an average age of 38 years. Substance abuse was found to be more stigmatizing than mental illness, F(1, 47) = 14.213, p.001, and stigma varied across four different levels of stigma (Aware, Agree, Apply, and Harm), F(2.099, 98.675) = 117.883, p.001. The interaction between type and level of stigma was also significant, F(2.41, 113.284) = 20.250, p.001, indicating that differences in reported stigma between types varied across levels of stigma. Post hoc tests found a significant difference between all levels of stigma except for the comparison between Apply and Harm. Reported stigma was significantly higher for substance abuse than mental illness at the Aware and Agree levels. In addition, pairwise comparisons found significant differences between all levels of stigma with the exception of the comparison between Apply and Harm, indicating a pattern whereby reported stigma generally decreased from the first level (Aware stage) to subsequent levels.These results have important implications for treatment, suggesting the need to incorporate anti-stigma interventions for individuals with co-occurring disorders with a greater focus on substance abuse.

Objectives Patterns and predictors of engagement in peer support services were examined among 50 previously homeless veterans with co-occurring mental health conditions and substance use histories receiving services from the Veterans Health Administration supported housing program. Method Veteran peer specialists were trained to deliver sessions focusing on mental health and substance use recovery to veterans for an intended 1-hr weekly contact over 9 months. Trajectories of peer engagement over the study's duration are summarized. A mixed-effects log-linear model of the rate of peer engagement is tested with three sets of covariates representing characteristics of the veterans. These sets were demographics, mental health and substance use status, and indicators of community participation and support. Results Data indicate that veterans engaged with peers about once per month rather than the intended once per week. However, frequency of contacts varied greatly. The best predictor of engagement was time, with most contacts occurring within the first 6 months. No other veteran characteristic was a statistically significant predictor of engagement. Older veterans tended to have higher rates of engagement with peer supporters. Conclusions and implications for practice Planners of peer support services could consider yardsticks of monthly services up to 6 months. Peer support services need a flexible strategy with varying levels of intensity according to need. Peer support services will need to be tailored to better engage younger veterans. Future research should consider other sources of variation in engagement with peer support such as characteristics of the peer supporters and service content and setting. (PsycINFO Database Record

Persons with mental health diagnoses use tobacco at alarming rates, yet misperceptions remain about the effect of quitting on mental health outcomes. This article examines the relationship between tobacco cessation and changes in severity of mental illness. Participants were N = 577 veterans with a history of mental health treatment enrolled in a tobacco cessation study. The effects of abstinence and time on Behavior and Symptom Identification Scale–24 summary scores and subscales were examined. Abstinence at both 2 and 6 months post-baseline was related ( p

Introduction People with a mental health diagnosis have high rates of tobacco use and encounter limited availability of tobacco treatment targeted to their needs. This study compared the effectiveness of a specialized telephone smoking-cessation intervention developed for mental health patients with standard state quit-line counseling. Design RCT. Setting/participants The study was conducted at six Veterans Health Administration facilities in the Northeast U.S. Participants were 577 mental health clinic patients referred by their providers for smoking-cessation treatment. Intervention From 2010 to 2012, the study implemented a telephone program that included patient referral from a mental health provider, mailed cessation medications, and telephone counseling. Participants were randomized to receive a specialized multisession telephone counseling protocol ( n =270) or transfer to their state's quit-line for counseling ( n =307). Main outcome measures Participants completed telephone surveys at baseline, 2 months, and 6 months. The study's primary outcome was self-reported 30-day abstinence at 6 months. Secondary outcomes were self-reported 30-day abstinence, counseling satisfaction and counseling content at 2 months, and self-reported use of cessation treatment and quit attempts at 6 months. Logistic regression was used to compare treatment groups on outcomes, controlling for baseline cigarettes per day and site. Inverse probability weighting and multiple imputation were used to handle missing abstinence outcomes. Data were analyzed in 2014−2015. Results At 6 months, participants in the specialized counseling arm were more likely to report 30-day abstinence (26% vs 18%, OR=1.62, 95% CI=1.24, 2.11). There was no significant group difference in abstinence at 2 months (18% vs 14%, OR=1.31, 95% CI=0.49, 3.49). Participants in the specialized arm were more likely to be assisted with developing a quit plan; receive follow-up calls after quitting; and receive counseling on several domains, including motivation, confidence, smoking triggers, coping with urges, and mental health symptoms (all p p Conclusions The specialized counseling intervention was more effective at helping patients quit than transfer to a state quit-line. Patients were more satisfied with the specialized counseling program. Trial registration This study is registered at www.clinicaltrials.gov NCT00724308.

Background and Objectives In spite of increased gambling opportunities, risk factors associated with recreational gambling remain poorly understood. This study assessed behavioral risk factors associated with frequency of recreational gambling. Methods Data were derived from the 2013 Massachusetts Behavioral Risk Factor Surveillance System. Gambling frequency was divided into two or more times per week, 1–4 times a month, less than 10 times in total, and not at all. Health risk behaviors included smoking, drinking, obesity, seat belt use, and sleep patterns. Multivariate logistic regression was used to assess relationships between overall gambling participation and gambling frequency and behavioral risk behaviors. Final analytical sample included 3,988 survey respondents. Statistical analyses were performed using STATA. Results Significant differences exist in the socio-demographic characteristics of recreational gamblers. Highest gambling frequency is associated with increased odds of alcohol consumption (ie, having at least one alcohol drink during the past 30 days) (OR 1.9; p

Opioid use disorders are considered a serious public health problem among young adults. Current treatment is limited to long-term opioid substitution therapy, with high relapse rates after discontinuation. This study evaluated the co-administration of memantine to brief buprenorphine pharmacotherapy as a treatment alternative.13-week double-blind placebo-controlled trial evaluating 80 young adult opioid dependent participants treated with buprenorphine/naloxone 16-4mg/day and randomized to memantine (15mg or 30mg) or placebo. Primary outcomes were a change in the weekly mean proportion of opioid use, and cumulative abstinence rates after rapid buprenorphine discontinuation on week 9.Treatment retention was not significantly different between groups. The memantine 30mg group was significantly less likely to relapse and to use opioids after buprenorphine discontinuation. Among participants abstinent on week 8, those in the memantine 30mg group (81.9%) were significantly less likely to relapse after buprenorphine was discontinued compared to the placebo group (30%) (p0.025). Also, the memantine 30mg group had significantly reduced opioid use (mean=0, SEM±0.00) compared to the placebo group (mean=0.33, SEM±0.35; p0.004) during the last 2 weeks of study participation.Memantine 30mg significantly improved short-term treatment with buprenorphine/naloxone for opioid dependent young adults by reducing relapse and opioid use after buprenorphine discontinuation. Combined short-term treatment with buprenorphine/naloxone may be an effective alternative treatment to long-term methadone or buprenorphine maintenance in young adults.

Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011–2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.

Background The U.S. is facing an opioid epidemic, but despite mandates for pharmacotherapy for opioid use disorder to be available at Veterans Health Administration (VHA) facilities, the majority of veterans with opioid use disorder do not receive these medications. In implementation research, facilities are often targeted for qualitative inquiry or quality improvement efforts based on quality measure performance during a one-year period. However, sites that experience quality performance changes from one year to the next may be highly informative because mechanisms that impact facility change may be more discoverable. The current study examined changes in receipt of pharmacotherapy for opioid use disorder in a national healthcare system to determine the extent to which sites fluctuated in performance over a two-year period and illustrate how changes in quality measures over time may be useful for implementation research and healthcare surveillance of quality measures. Methods Using national VHA data from Fiscal Years (FY) 2016 and 2017, we calculated quality measure performance as the number of patients who received pharmacotherapy for opioid use disorder (i.e., methadone, buprenorphine, and naltrexone) divided by the number of patients with a current non-remitted opioid use disorder diagnosis for each FY at each facility (n = 129) and examined change from FY16 to FY17. Results The mean rate of receipt of pharmacotherapy for opioid use disorder was 38% (facility range = 3% to 74%) in FY16 and 41% (facility range = 2% to 76%) in FY17. The average facility-level change in performance was 3% and ranged from −19% to 26%. There were 32 facilities that decreased in provision of pharmacotherapy, 12 facilities with no change, and 85 facilities that increased. Conclusions For facilities with average or high performance, it was difficult to maintain their performance over time. Identifying and learning from facilities with recent fluctuations may be more informative to guide the design of future quality improvement efforts than studying facilities with stable high or low performance.

Background Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet. Methods This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models. Results Treatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received “higher” and “lower” intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use. Conclusions Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care. Trial registration Clinicaltrials.gov, registration number: NCT01430741, registered July 26, 2011.

This article reports on the implementation, evaluation, and policy implications of MISSION-Criminal Justice (CJ), an innovative intervention used to treat justice-involved veterans with co-occurring mental health and substance use disorders (CODs). In this pilot feasibility study, MISSION-CJ was embedded into four Massachusetts courts and their probation services as an alternative to incarceration. Seventy-six veterans were diverted from jail to MISSION-CJ and completed intake and six-month follow-up assessments. The MISSION-CJ participants were primarily white, had at least two prior arrests, served in a war combat zone, had a trauma before age 18, and had previously received mental health and substance use treatments. Preliminary six-month follow-up data suggested that the MISSION-CJ participants showed improvements in COD problems, trauma symptoms, and a nonsignificant reduction in hospitalization/ER visits. MISSION-CJ was feasible to implement and seemed to show some preliminary program success. A randomized controlled trial of MISSION-CJ is a necessary next step in determining program efficacy. Policy implications for tailoring interventions for justice-involved veterans such as MISSION-CJ and their delivery alongside the court and probation are discussed.

This study uniquely evaluates the prevalence of recreational gambling, and co-occurring conditions prior to gambling expansion in Massachusetts (MA), and assesses associations between gambling and co-occurring behavioral, and mental health disorders. Data are derived from the 2008 MA Behavioral Risk Factor Surveillance System. Logistic regression models to obtain multivariate adjusted odds ratios (ORs) for factors associated with gambling are performed. Prevalence of recreational gambling in MA is 40.2 % (95 % CI 38.2–42.1). Gamblers are more likely to be obese (OR 1.3, 95%CI 1.0–1.7; p

This study assessed perceptions of voluntary consent among 69 veterans who enrolled in a "jail diversion" program for co-occurring disorders. Perceptions were measured using modified items from the MacArthur Perceived Coercion and Negative Pressure Scales. A majority reported that they "chose to" (88.4%) or "felt free to" (85.5%) enroll. Most reported having "control over" (69.6%) and "more influence than anyone else" regarding (60.9%) their participation. About half reported that enrollment was "their idea" (49.3%). Fewer reported perceptions of negative pressure, including the feeling that someone "talked them into" enrolling (24.6%), "threatened them with the maximum criminal punishment" (13.0%), "offered or promised them something" (5.8%), or "forced" them to enroll (5.8%). Nobody felt "tricked, lied to, or fooled into" participating. Total negative pressure scores were higher in those with combat experience, U = 406.50, p = .016. Although potentially inappropriate pressures were reported, these data suggest that the majority perceived enrollment as voluntary.

Background Approximately 600,000 persons are released from prison annually in the United States. Relatively few receive sufficient re-entry services and are at risk for unemployment, homelessness, poverty, substance abuse relapse and recidivism. Persons leaving prison who have a mental illness and/or a substance use disorder are particularly challenged. This project aims to create a peer mentor program to extend the reach and effectiveness of reentry services provided by the Department of Veterans’ Affairs (VA). We will implement a peer support for reentry veterans sequentially in two states. Our outcome measures are 1) fidelity of the intervention, 2) linkage to VA health care and, 3) continued engagement in health care. The aims for this project are as follows: (1) Conduct contextual analysis to identify VA and community reentry resources, and describe how reentry veterans use them. (2) Implement peer-support, in one state, to link reentry veterans to Veterans’ Health Administration (VHA) primary care, mental health, and SUD services. (3) Port the peer-support intervention to another, geographically, and contextually different state. Design This intervention involves a 2-state sequential implementation study (Massachusetts, followed by Pennsylvania) using a Facilitation Implementation strategy. We will conduct formative and summative analyses, including assessment of fidelity, and a matched comparison group to evaluate the intervention’s outcomes of veteran linkage and engagement in VHA health care (using health care utilization measures). The study proceeds in 3 phases. Discussion We anticipate that a peer support program will be effective at improving the reentry process for veterans, particularly in linking them to health, mental health, and SUD services and helping them to stay engaged in those services. It will fill a gap by providing veterans with access to a trusted individual, who understands their experience as a veteran and who has experienced justice involvement. The outputs from this project, including training materials, peer guidebooks, and implementation strategies can be adapted by other states and regions that wish to enhance services for veterans (or other populations) leaving incarceration. A larger cluster-randomized implementation-effectiveness study is planned. Trial registration This protocol is registered with clinicaltrials.gov on November 4, 2016 and was assigned the number NCT02964897. Electronic supplementary material The online version of this article (10.1186/s12913-017-2572-x) contains supplementary material, which is available to authorized users.

The Veterans Health Administration (VA) Health Care for Reentry Veterans (HCRV) program links veterans exiting prison with treatment. Among veterans served by HCRV, national VA clinical data were used to describe contact with VA health care, and mental health and substance use disorder diagnoses and treatment use. Of veterans seen for an HCRV outreach visit, 56 % had contact with VA health care. Prevalence of mental health disorders was 57 %; of whom 77 % entered mental health treatment within a month of diagnosis. Prevalence of substance use disorders was 49 %; of whom 37 % entered substance use disorder treatment within a month of diagnosis. For veterans exiting prison, increasing access to VA health care, especially for rural veterans, and for substance use disorder treatment, are important quality improvement targets.