Traci Rieckmann

Cultural Identity, Explanatory Style, and Depression in Navajo Adolescents.

This study investigated the interrelationships among cultural identity, explanatory style, and depression in Navajo adolescents. A total of 332 (197 female, 135 male) Navajo adolescents completed 7 self-report measures. These data were used to create, via structural equation modeling, a series of factor models and full structural models. Analyses indicated that current factor structures for explanatory style and depression are adequate for use with Navajo adolescents. Increased control and predictability and limited duration of stressful encounters were both predictive of decreased symptoms of depression. Higher levels of Navajo cultural identity had a modest effect in terms of reducing depression. Other factors, such as perceived discrimination and urban/reservation domicile, are important to study to provide an increased understanding of depression among Navajo adolescents.

Training rural practitioners to use buprenorphine: Using The Change Book to facilitate technology transfer

The Opiate Medication Initiative for Rural Oregon Residents trained physicians and counselors in Central and Southwestern Oregon to use buprenorphine and develop service models that supported patient participation in drug abuse counseling. The Change Book from Addiction Technology Transfer Centers was used to structure the change process. Fifty-one individuals (17 physicians, 4 pharmacists, 2 nurse practitioners, and 28 drug abuse counselors and administrators) from seven counties completed the training and contributed to the development of community treatment protocols. A pre-post measure of attitudes and beliefs toward the use of buprenorphine suggested significant improvements in attitude after training, especially among counselors. Eight months after training, 10 of 17 physicians trained had received waivers to use buprenorphine and 29 patients were in treatment with six of the physicians. The Change Book facilitated development of county change teams and structured the planning efforts. The initiative also demonstrated the potential to concurrently train physicians, pharmacists, and counselors on the use of buprenorphine.

Implementation of Evidence-Based Practices for Treatment of Alcohol and Drug Disorders: The Role of the State Authority

The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.

Behavioral Health Insurance Parity: Does Oregon's Experience Presage the National Experience With the Mental Health Parity and Addiction Equity Act?

OBJECTIVE The Mental Health Parity and Addiction Equity Act of 2008 prohibits commercial group health plans from imposing spending and visit limitations for mental health and substance abuse services that are not imposed on medical-surgical services. The act also restricts the use of managed care tools that apply to behavioral health benefits in ways that differ from how they apply to medical-surgical benefits. The only precedent for this approach is Oregons state parity law, which was implemented in 2007. The goal of this study was to estimate the effect of Oregons parity law on expenditures for mental health and substance abuse treatment services. METHOD The authors compared expenditures for commercially insured individuals in four Oregon health plans from 2005 through 2008 and a matched group of commercially insured individuals in Oregon who were exempt from parity. Using a difference-in-differences analysis, the authors analyzed the effect of comprehensive parity on spending for mental health and substance abuse services. RESULTS Increases in spending on mental health and substance abuse services after implementation of Oregons parity law were almost entirely the result of a general trend observed among individuals with and without parity. Expenditures per enrollee for mental health and substance abuse services attributable to parity were positive, but they did not differ significantly from zero in any of the four plans. CONCLUSIONS Behavioral health insurance parity rules that place restrictions on how plans manage mental health and substance abuse services can improve insurance protections without substantial increases in total costs.

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment.

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

Implementation of MET/CBT 5 for Adolescents

Implementation of effective substance abuse treatment programs in community settings is a high priority. The selection of a proven cost-effective model is a first step; however, difficulty arises when the model is imported into a community setting. The Center on Substance Abuse Treatment selected a brief substance abuse treatment program for adolescents, the MET/CBT-5 program, determined to be the most cost-effective protocol in the Cannabis Youth Treatment trial, for implementation in two cohorts of Effective Adolescent Treatment grantees. A qualitative investigation of the protocol implementation with nine sites in the second cohort chronicled adaptations made by grantees and prospects for sustainability. The study found that agencies introduced adaptations without seeming to be aware of potential effects on validity. In most sites, sessions were lengthened or added to accommodate individual client needs, address barriers to client participation, and provide consistency with current norms of treatment. Implications for fidelity of future implementation projects are addressed.

Employing Policy and Purchasing Levers to Increase the Use of Evidence-Based Practices in Community-Based Substance Abuse Treatment Settings: Reports from Single State Authorities.

State public health authorities are critical to the successful implementation of science based addiction treatment practices by community-based providers. The literature to date, however, lacks examples of state level policy strategies that promote evidence-based practices (EBPs). This mixed-methods study documents changes in two critical state-to-provider strategies aimed at accelerating use of evidence-based practices: purchasing levers (financial incentives and mechanisms) and policy or regulatory levers. A sample of 51 state representatives was interviewed. Single State Authorities for substance abuse treatment (SSAs) that fund providers directly or through managed care were significantly more likely to have contracts that required or encouraged evidence-based interventions, as compared to SSAs that fund providers indirectly through sub-state entities. Policy levers included EBP-related legislation, language in rules and regulations, and evidence-based criteria in state plans and standards. These differences in state policy are likely to result in significant state level variations regarding both the extent to which EBPs are implemented by community-based treatment providers and the quality of implementation.

Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach

Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselors attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.

Medicaid Reimbursement for Screening and Brief Intervention for Substance Misuse

OBJECTIVES Effective January 2008, state Medicaid plans may reimburse for screening and brief intervention for alcohol and drug misuse. This study assessed state Medicaid activity to implement Healthcare Common Procedure Code System codes and pay for screening and brief intervention. METHODS State and District of Columbia Medicaid representatives (N=44) participated in semistructured telephone interviews (N=37) or provided e-mail correspondence (N=7) about implementation of reimbursement codes. Confirmatory Web searches of Medicaid fee schedules supplemented findings and provided information for the remaining seven states. RESULTS More than half the states (N=28) list designated screening and brief intervention codes in their state Medicaid fee schedules; 19 of those states are capable of reimbursing for the codes. Qualitative analysis examined the challenges in choosing codes, assigning reimbursement rates, and working within constrained Medicaid budgets. CONCLUSIONS Implementation of billing codes appears to be an insufficient policy mechanism to promote utilization of screening and brief intervention for treating substance use.

American Indians with substance use disorders: treatment needs and comorbid conditions.

Background: American Indians and Alaska Natives (AI/ANs) experience significant disparities in health status and access to care. Furthermore, only limited data are available on substance use, mental health disorders, and treatment needs for this population. Addressing such disparities and developing culturally relevant, effective interventions for AI/AN communities require participatory research. Objectives and Methods: The Western States Node of the National Institute on Drug Abuse Clinical Trials Network partnered with two American Indian substance abuse treatment programs: an urban health center and a reservation-based program to assess client characteristics, drug use patterns, and treatment needs. Data collected by staff members at the respective programs from urban (n = 74) and reservation (n = 121) clients were compared. Additional sub-analysis examined patients reporting regular opioid use and mood disorders. Results: Findings indicate that urban clients were more likely to report employment problems, polysubstance use, and a history of abuse. Reservation-based clients reported having more severe medical problems and a greater prevalence of psychiatric problems. Clients who were regular opioid users were more likely to report having a chronic medical condition, suicidal thoughts, suicide attempts, polysubstance abuse, and IV drug use. Clients who reported a history of depression had twice as many lifetime hospitalizations and more than five times as many days with medical problems. Conclusions: Findings from this project provide information about the patterns of substance abuse and the importance of comprehensive assessments of trauma and comorbid conditions. Results point to the need for integrative coordinated care and auxiliary services for AI/AN clients seeking treatment for substance use disorders.