Proceedings of the Addiction Health Services Research (AHSR) 2020: Virtual Conference: Part 2

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Background: In Florida, House Bill 21 (HB21) was implemented in July 2018 to limit prescriptions of Schedule II opioids for acute pain patients to a 3-day supply. In response to restrictions to opioid prescriptions, drug utilization patterns of commonly co-prescribed medications might shift among chronic pain patients. Currently, little is known about the unintended impacts of opioid supply policy restrictions on adjuvant medication use. Methods: We obtained prescription claims for medications dispensed from 1/1/2015 to 6/31/2019 from a health plan serving a large Florida employer. Interrupted time series analyses were conducted to compare pre and post-implementation changes in mean monthly number of users and prescriptions per 1000 enrollees for adjuvant medications: gabapentinoids, benzodiazepines, and muscle relaxants. Results: There was a significant decrease in the mean monthly proportion of benzodiazepines users (17.37·1.26 vs. 14.12·0.61) and number of prescriptions (30.25·2.76 vs. 25.34·2.00) per 1000 patients. There were no significant changes in the mean monthly proportion of gabapentinoids users (9.01·0.35 vs. 9.71·0.50), gabapentinoid prescriptions (19.68·1.40 vs. 22.77·2.08), muscle relaxants users (13.31·0.67 vs. 12.33·0.97), or muscle relaxant prescriptions (23.41·1.91 vs. 22.45·2.29) per 1000 patients. Adjusting for key variables, there was an immediate 6% increase in monthly proportion of gabapentinoids users (RR: 1.06, 95% CI 1.02, 1.11) and an immediate 11% increase in gabapentinoid prescriptions (RR: 1.11, 95% CI 1.04, 1.18) per 1000 patients. Additionally, there was a 7% immediate reduction for monthly proportion of benzodiazepines users (RR: 0.93, 95% CI 0.89, 0.97), and a significant 15% reduction in trend was observed in monthly proportion of muscle relaxants users (RR: 0.98, 95% CI 0.97, 0.99; 0.83, 95% CI 0.77, 0.90) after the HB21 enactment. Conclusion: Following the Florida opioid restriction law for acute pain, there were increased number of patients and prescriptions for gabapentinoids, however fewer patients received benzodiazepines and muscle relaxants in the post-implementation period. Background: Although estimates of opioid-related fatalities in the United States indicate a decrease from 2017 to 2018, deaths associated with the opioid epidemic continue to rise among low-income and minority populations. Despite efficacy of medication for opioid use disorder (MOUD), these populations are vulnerable to poor treatment outcomes. Peer recovery coaches (PRCs), individuals with lived experience of substance use and recovery, are well-positioned to engage vulnerable patients. Traditionally, PRCs have focused on bridging to care rather than delivering interventions themselves. This study used qualitative methods to solicit feedback on feasibility and acceptability of PRC-delivered Behavioral Activation (BA) to support retention in MOUD by increasing positive reinforcement. Methods: This study was conducted at a community-based drug treatment center that serves low-income, minority patients and reports an average 49% retention at 6 months post-treatment initiation. We recruited patients and staff as well as PRCs who work across the city. Semi-structured interviews and focus groups inquired about feasibility and acceptability of a BA intervention, recommendations for adaptation for the target population, and comfort working with a peer in the context of MOUD. Results: Participants (n = 20) had a mean age of 48.4 (SD = 10.0), were 70% male, and 60% Black or African American. Staff and PRC participants (n = 12) had a mean age of 49.2 (SD = 0.7), were 42% male, 75% Black or African American, with an average of 9.6 years working in substance use treatment. Participants shared that PRC-delivered BA could be feasible and acceptable with adaptations, including emphasis on PRC-led/taught activities. They described common challenges associated with unstructured time, for which BA could be particularly relevant. Conclusions: Improving MOUD outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Qualitative feedback suggests PRCs may be effective in this effort and our research findings inform an upcoming PRC-delivered BA trial.

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"Improving transitions of care for patients initiated on buprenorphine from the emergency department" (TR08) Callan E. Fockele, Herbie C. Duber, Brad Finegood, Sophie C. Morse, and Lauren K. Whiteside Lead Author Affiliation: Harborview Medical Center, 325 Ninth Avenue Seattle WA 98104-2499, USA Correspondence: Callan E. Fockele (cfockele@uw.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A14 Background: Opioid use disorder (OUD) is on the rise nationwide with increasing emergency department (ED) visits and deaths secondary to overdose. Although previous research has shown that patients who are started on buprenorphine in the ED have increased engagement in addiction treatment, access to on-demand medications for OUD is still limited, in part because of the need for outpatient linkages to care. The objective of this study is to describe emergency and outpatient providers' perception of local barriers to transitions of care for ED-initiated buprenorphine patients. Methods: Purposive sampling was used to recruit key stakeholders, who identified as physicians, addiction specialists, and hospital administrators, from 10 EDs and 11 outpatient clinics in King County, Washington. Twenty-one interviews were recorded and transcribed, and then coded by two team members in order to verify accuracy of the thematic analysis. Interview guides and coding were informed by the Consolidated Framework for Implementation Research (CFIR), which provides a structure of domains and constructs associated with effective implementation of evidence-based practice. Results: From the 21 interviews with emergency and outpatient providers, this study used the CFIR construct of compatibility situated within the domain of the inner setting to identify four barriers to transitions of care for ED-initiated buprenorphine patients: scope of practice, prescribing capacity, referral incoordination, and loss to follow-up. Conclusion: Next steps for implementation of this intervention in a community setting include: establishing a standard of care around treatment and referral for ED patients with OUD, increasing buprenorphine prescribing capacity, creating a central repository for streamlined referrals and follow-up, and supporting low barrier scheduling and navigation services. Addict Sci Clin Pract 2020, 15(Suppl 2):35 any human contact. Automated feedback messages that are tailored to individuals' barriers and facilitators to drug use reduction may be a scalable, yet personalized, strategy to enhance counselor delivered interventions and sustain patient engagement in drug use reduction goals after counseling sessions cease. This analysis aimed to identify barriers and facilitators to drug use reduction to guide tailoring of personalized feedback text-messages in response to weekly self-monitoring by patients with moderate risk drug use in the new NIDA-funded QUIT-Mobile study. Methods: Analysis included thematic content analysis of QUIT-Binational study health educator coaching log data. Two research assistants closely examined the data to identify common themes through iterative rounds of coding and discussion with the study team. Results: The most common barriers to drug use reduction cited by QUIT-Binational participants were: (1) peers/social environment, (2) relaxation and being able to "mellow out", (3) pain relief, and (4) perceived to work better than prescribed medication. The most common facilitators that helped participants stay focused on their drug use reduction goals were: (1) exercise, (2) family and peer support, (3) motivation in spending less money, (4) alternative pain relief (i.e. stretching), and (5) relaxation techniques (i.e. meditation, journaling). Conclusion: Findings suggest there are unique barriers and facilitators to drug use reduction in diverse low-income primary care patients. Feedback messages should be tailored to individuals' noted barriers and facilitators to enhance motivation and reinforce alternatives to drug use. Future studies should comprehensively examine how cultural, social, and environmental aspects influence drug use to develop specialized feedback that appeals to diverse patients to a greater degree than standard feedback.
Background: Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with feedback reports (EM/AF), (2) practice facilitation (PF), and (3) prescriber peer consulting (PPC). This NIH-funded (R01DA047279) study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in primary care clinics. Methods: The study is a hybrid type 3 clustered, sequential, multipleassignment randomized trial that randomizes 40 clinics from two health systems at months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of EM/AF, EM/AF plus PF, EM/AF + PPC, and EM/ AF + PF + PPC. Results: The primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The primary aim is the comparison of EM/AF + PF + PPC versus EM/AF on change in MME from month 3 to month 21. The secondary aim is to derive and compare cost estimates for each of the four sequences. Conclusion: Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study will help understand how to cost effectively improve the implementation of evidence-based practices.

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"Development and evaluation of a technology-assisted intervention for parents of adolescents in residential substance use treatment" (TR17) Sara J. Becker, Sarah A. Helseth, Katherine I. Escobar, Timothy Janssen, and Anthony Spirito Lead Author Affiliation: Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA Correspondence: Sara J. Becker (sara_becker@brown.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A23 Background: Approximately 60% of adolescents in residential substance use (SU) treatment relapse within 90 days of discharge. Parenting skills predict adolescent SU outcomes and likelihood of relapse, but engaging parents in treatment is challenging. Accordingly, there is a clear need for effective and scalable interventions for parents of adolescents in residential SU treatment. This pilot trial evaluated the feasibility, acceptability, and effectiveness of a technology-assisted parenting intervention called Parent SMART, as an adjunct to residential treatment as usual (TAU). Methods: Parent SMART augments an off-the-shelf, research-tested, online parenting program (Parenting Wisely) with two scalable components: (1) up to four telehealth sessions, and (2) a mobile networking app, where parents can submit questions to an SU expert or connect with other parents of adolescents in residential treatment. We randomized 61 adolescent-parent dyads from two residential SU treatment programs to either TAU (n = 31) or Parent SMART + TAU (n = 30). Assessments at baseline, 6-, 12-, and 24-weeks post-discharge examined parenting skills, adolescent days of SU, and adolescent problems. Results: Feasibility and acceptability targets were met or exceeded: 86% of parents completed at least 2 telehealth sessions and 2 online modules, 70% posted in the networking app, and 85-90% were retained at follow-up. Parents were significantly more satisfied with and likely to recommend Parent SMART to a friend than TAU. Mixed effect models revealed that Parent SMART was significantly more effective over time in increasing parental monitoring and communication, in reducing days of drinking, and in reducing school-related problems among parents of adolescents in the short-term residential program. Conclusion: Results provide evidence of feasibility, acceptability, and preliminary effectiveness of Parent SMART as an adjunct intervention to improve outcomes among high-risk adolescents at a vulnerable time in their recovery process. Background: Screening for alcohol and drug use is recommended for adult primary care patients, but primary care clinics frequently struggle to choose the approach that is best suited to their resources, workflows, and patient populations. To inform these decisions, we conducted a multi-site study to inform the implementation and feasibility of electronic health record (EHR)-integrated screening. Methods: In two urban academic health systems, researchers worked with stakeholders from six clinics to define and implement their optimal screening approach. All clinics used single-item screening questions for alcohol/drugs followed by the AUDIT-C/DAST-10 for patients screening positive. Clinics chose between screening at routine vs. Addict Sci Clin Pract 2020, 15(Suppl 2):35 annual visits; and staff-administered vs. electronic self-administered screening. Results were recorded in the EHR, and data was extracted quarterly to describe implementation outcomes. Findings are from the first year after implementation. Results: Across all clinics, among 93,114 patients with primary care visits, 72% were screened for alcohol and 71% were screened for drugs. Screening at routine encounters, in comparison to annual visits, achieved higher screening rates for alcohol (90-95% vs. 24-72%) and drugs (90-94% vs. 25-70%). Clinics using staff-administered screening, in comparison to patient self-administered screening, had lower rates of detection of unhealthy alcohol use (1.6% vs. 14.7-36.6%). Detection of unhealthy drug use was low at all clinics, ranging from 0.5 to 1.0%. Conclusion: EHR-integrated screening was feasible to implement in all six clinics, though one had persistently lower screening rates than the others. Screening at routine primary care visits with a selfadministered approach offered the most opportunities for identifying unhealthy alcohol use. Detection of drug use was low regardless of screening approach. Although limited by differences among clinics, this study provides insight into outcomes that may be expected with commonly used screening strategies in primary care. Background: Patients in methadone maintenance treatment (MMT) demonstrate high rates of co-occurring disorders (CODs). However, limited information exists about CODs in increasingly rural settings, particularly among Medicaid/Medicare beneficiaries. Our objectives were to identify rates and correlates of CODs, and differences between patients with and without past-year (PY) opioid misuse. Methods. Medicaid/Medicare beneficiaries (N = 219) with opioid use disorder (OUD) (female = 61.9%, Non-Hispanic White = 85.8%; PY opioid misuse = 48.4%) completed cross-sectional surveys at an opioid treatment program providing MMT in a small urban setting surrounded by rural communities. Measures included sociodemographic and opioid characteristics, and screens for co-occurring emotional (current depression, anxiety, PTSD; PHQ-4, PC-PTSD-5) and substance use disorders (SUDs) (PY alcohol, cannabis, stimulant, sedative use disorders; AUDIT-C, SDS). Results: At least one positive COD screen was observed in 78.1% of patients, with rates as follows: anxiety (48.4%), PTSD (44.0%), depression (41.2%), and disordered use of stimulants (30.1%), cannabis (19.2%), alcohol (16.1%), and sedatives (7.8%). Within OUD patients reporting PY opioid misuse, 89.6% screened positive for CODs, and the same group demonstrated higher rates for six CODs (stimulant: X2 = 34.93, P < 0.001; PTSD: X2 = 13.22, P < 0.001; sedative: X2 = 11.71, P < 0.001; anxiety: X2 = 8.47, P = 0.004; cannabis: X2 = 6.94, P = 0.008; alcohol: X2 = 4.75, P = 0.029). Across the sample, co-occurring sedative use disorder was more common among patients with less than a high school degree (X2 = 5.53, P = 0.019), overdose histories (X2 = 5.18, P = 0.023), and self-reported fentanyl use (X2 = 5.25, P = 0.034). Patients reporting fentanyl use demonstrated a higher rate of positive screens for PTSD (X2 = 8.39, P = 0.004) and stimulant use disorder (X2 = 5.18, P = 0.023). Race and gender did not differentiate CODs. Conclusion: This analysis identifies high COD rates among a population underrepresented in the MMT literature. A single opioid misuse item was a key distinguisher of CODs. Integrated approaches are needed to address the COD burden in this underserved population.

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"Defining patient-centered successful methadone treatment outcomes among low-income, minority individuals at a community-based outpatient treatment center" (HD02) Background: In 2018, nearly 70% of drug overdose fatalities were attributable to opioids, disproportionately impacting low-income, ethnoracial minority individuals. Medication for opioid use disorder (MOUD) has established efficacy, yet less than 50% of patients are retained in care at 6 months with research pointing to the importance of 6-month retention for long-term treatment outcomes. While MOUD success is often defined through abstinence and relapse, a more comprehensive understanding of successful outcomes may help inform efforts to increase treatment success and improve quality of life. This study seeks to define patient-centered successful MOUD outcomes through qualitative work at an outpatient methadone program serving a predominantly low-income, ethnoracial minority population in Baltimore City. Methods: Semi-structured interviews (n = 9) and focus groups (n = 23) were conducted with patients, staff, and peer recovery coaches (PRCs) at an opioid treatment program. Patients were asked what doing well in the methadone program looked/felt like. Staff and PRCs were asked to define treatment success based on their clients' experiences. Interviews and focus groups were transcribed and thematically coded to consensus by two trained coders. Results: Patients (n = 20) had a mean age of 48.4 (SD = 10.0), were 70% male, and 60% Black or African American. Staff and PRCs (n = 12) had a mean age of 49.2 (SD = 0.7), were 42% male, and 75% Black or African American. Participants identified patient-centered successful treatment outcomes as improved health (mental/physical), stability and productivity (stable housing, employment), social behaviors (mending/building relationships), improved sense of self-worth (pride, valuing life), absence of substance-driven behaviors (saving paychecks, avoiding negative influences), MOUD engagement (maintaining stable dose, planned/tapered methadone discontinuation), and reduction in or abstinence from substance use. Conclusion: Understanding patient-centered definitions of successful MOUD outcomes may help inform interventions aiming to improve treatment retention and success. Our findings will inform how treatment success is defined and evaluated in a subsequent clinical trial at this site. Keywords (2-5): medication treatment for opioid use disorder, retention, treatment outcomes.

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"Differences in recovery from alcohol and drug problems in the United States population based on LGBTQ+ status: prevalence, pathways, and psychological well-being" (HD03) Amanda K. Background: Alcohol and other drug (AOD) use disorders are a significant public health concern and LGBTQ+ individuals are overrepresented among this population likely due to substantial biobehavioral stress from stigmatization. Little is known about the characteristics of this population and differences between LGBTQ+ and heterosexual individuals on clinical and service use histories and current well-being in recovery. Addict Sci Clin Pract 2020, 15(Suppl 2):35 Methods: Data are from the National Recovery Study-a nationally representative sample of US adults (18+) who have resolved an AOD problem (N = 2002). Chi-square or ANOVA tests tested for differences in socio-demographics and AOD use/treatment and psychiatric/legal factors. Unadjusted linear regression analyses tested for group differences on indices of current well-being (e.g., psychiatric distress, quality of life, happiness, self-esteem). LOWESS graphs were computed to show differences between groups across time on well-being indices. Linear regression models factored in variables that were significantly different between groups in univariate analyses in order to investigate which variables might account for observed differences on indices of well-being. Results: 11.7% identified as LGBTQ+. Compared to heterosexual individuals (n = 1666), LGBTQ+ (n = 220) were less likely to be employed (OR = 0.64; 95% CI 0.43, 0.96) and had significantly fewer years since problem resolution (OR = 0.97; 95% CI 0.96, 0.99). LGBTQ+ also evidenced more markers of severity, including being 2.2 times as likely to have a co-occurring psychiatric disorder (95% CI 1.49, 3.37). Unadjusted models showed that LGBTQ+ had significantly worse levels on all well-being indices. Models factoring in significantly different socio-demographic, AOD use/treatment, and psychiatric/legal factors explained most of these differences, except for psychological distress.

Conclusion:
LGBTQ+ individuals evinced more problematic psychiatric and legal histories and faced greater psychosocial challenges in recovery. Further research is needed to better understand the unique experiences of recovering LGBTQ+ individuals in order to address observed disparities in well-being.

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"Growth in recovery among emerging adults from ethnic minority backgrounds: impact of social support and life events" (HD04) Craig Henderson, Tessa Long, Lauren Ryan, Temilola Salami, Amanda Venta, and Elise Yenne Lead author affiliation: Sam Houston State University, 1905 University Ave, Huntsville, TX 77340, USA Correspondence: Craig Henderson (chenderson@shsu.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A28 Background: Substance use peaks during emerging adulthood and leads to negative outcomes well into the adult years. The negative consequences of substance use are particularly noteworthy in ethnic minority groups. Discrimination has been highlighted in previous research with ethnic minority populations as a salient factor underlying escalating substance use, but it has not been studied in clinical samples of emerging adults. Emerging adulthood has been highlighted as a sensitive period for increased exposure to discriminatory acts for ethnic minority youth, and the entrenchment of substance use behaviors across ethnicity. We examined the following hypotheses: (1) perceived discrimination will be associated with longitudinal trajectories of substance use such that higher levels of discrimination are associated with increasing levels of substance use; (2) time-varying associations between discrimination and substance use trajectories will be moderated by assumption of adult roles; (3) timevarying associations between discrimination and substance use trajectories will be moderated by social support. Methods: Hypotheses were evaluated using the current study used data from the Global Appraisal of Individual Needs dataset. Propensity score matching was first use to balance participants who reported perceiving that they had been discriminated against and those who had not on a number of background variables (final n = 386). Latent growth curve modeling was used to test study hypotheses. Results: contrary to expectations, participants reporting discrimination were more likely to enter recovery over the 12 month follow-up period. However, when social support and emerging adult life events were taken into account the effect was smaller. Results of the final model indicated that early, consistent employment was most influential in promoting participant recovery regardless of whether or not participants identifying as ethnic minority perceived they had been discriminated against.

Conclusion:
Securing employment during substance use treatment helps offset the negative impact of discrimination among emerging adults.

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"Identifying disparities in unmet behavioral health need and treatment initiation among youth on probation" (HD05) Margaret Ryan, Katherine Elkington, and Gail Wasserman Lead author affiliation: New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA Correspondence: Margaret Ryan (Margaret.Ryan@nyspi.columbia.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A29 Background: Youth on probation have a high burden of behavioral health (BH) treatment need, including mental health (MH) and substance use (SU). The pathway to treatment includes screening for BH need, referral, and initiation. Moreover, these pathways vary by need type, yet whether these differences are associated with disparities in need, referral and initiation is unknown. We aimed to examine this association and to identify whether BH need type (MH, SU or both) might influence these outcomes among juvenile probationers. Methods: Administrative data on BH screening [Youth Assessment and Screening Instrument (YASI)], referral, and initiation were collected from 10 NYS probation departments (08/01/2019 through 05/31/2020; N = 697 Juvenile Delinquent intakes). We examined need type (MH Only, SU Only, or Both MH and SU), controlling for age, gender, and race along each step in a series of multivariate logistic regression analyses. Results: Proportion of unmet need varied by identified need type: 67% of MH (126 of 187), 90% of SU (45 of 50), and 80% of both (78 of 98), as did treatment initiation among those with unmet need: 13% of MH (16 of 126), 7% of SU (3 of 45), and 15% of both (12 of 78). Controlling for demographics, youth with SU need were three times more likely to have untreated need (OR = 3.22 [95% CI 1.19,8.75], p = 0.022), compared with those with MH need. Conclusion: Findings point to disparities between the amount of probationers identified with unmet SU and MH treatment need and linked with treatment. Factors that likely contribute to these disparities, including low availability of adolescent SU services and lack of collaboration between probation and treatment, are discussed.

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"Examining existing barriers to public health interventions and medical services for rural people who use drugs in the COVID-19 era" (HD06) Background: The COVID-19 pandemic has led to unprecedented public health measures such as social distancing and changes to services including restricting face-to-face encounters and the acceleration of telemedicine. People who use drugs in rural areas may be increasingly vulnerable in this setting. Objectives: We explore potential predisposing factors impacting access to information and care for rural people who inject drugs (PWID) and/or people who used opioids (PWUO) non-medically in the pre-COVID era. Methods: We surveyed rural PWID/PWUO before the pandemic regarding social determinants, drug use, barriers to medical and substance use treatment, and technology use and generated descriptive statistics using R Suite.(tm). Results: Between July 2018 and July 2019, 173 current PWID/PWUO were surveyed (58% male; 86% White, 10% Black, 1.7% American Indian; mean age 40 years). Methamphetamines were the most frequently used drug (88% in the past 30 days) followed by opioid Addict Sci Clin Pract 2020, 15(Suppl 2):35 painkillers (73%), and benzodiazepines (70%). 49% had been homeless in the past 6 months. 21% were uninsured while 66% had Medicaid or Medicaid expansion. Only 49% had transportation to appointments, 26% could not pay for care, 20% did not trust doctors, and 44% feared they would be treated with disrespect. Over half felt uncertain or disagreed that they would hear about an infection spreading amongst PWID. Word of mouth was the most common way respondents thought they would hear about an infection (66%), followed by television (21%) and social media (12%). 33% reported accessing the internet less than daily and 31% did not have active cell phone service. Conclusion: Existing barriers such as homelessness, poverty, and distrust of providers may limit measures such as quarantine and selfisolation. Telemedicine may mitigate transportation barriers, however this may be undermined by lack of phone service, costs, and underlying stigma faced by PWID/PWUO. Peer interventions may leverage existing networks to disseminate information.

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"Examining the impact of jail sanctions on drug court program completion" (HD07) Lisa Shannon, Afton Jones, Jennifer Newell, and Elizabeth Nichols Lead author affiliation: Morehead State University, 150 University Blvd, Morehead, KY 40351, USA Correspondence: Lisa Shannon (l.shannon@moreheadstate.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A31 Background: Drug court is a community-based rehabilitation program for individuals with substance use issues and criminal justice involvement. Extant drug court research suggests effectiveness via reduced recidivism and other positive outcomes, particularly for graduates. Emerging research has shown the impact of sanctions/ therapeutic responses on program completion. Data from Wu and colleagues (2012) suggested program graduates were less likely to receive jail sanctions in comparison to program terminators. Another study showed the timing of the first sanction is also highly predictive of program retention (Brown, Allison & Nieto 2010). The current study's purpose was to further examine the impact of jail sanctions on drug court program completion. Methods: Fourteen Kentucky Drug Court (KDC) sites were sampled to represent each of the service regions statewide. A random sampling plan identified program participants (between February 16, 2008to December 13, 2013 for inclusion (n = 50) from each selected site. Data from the assessment at program entry, Management Information System, and criminal justice involvement were examined. Results: Bivariate analyses examined between-group differences based on completion status (graduates: n = 286; terminators: n = 414). Multivariate analysis utilizing Cox regression examined variables associated with program completion status accounting for the passage of time. Participants who had a jail sanction within the first 30 days of drug court participation had an increased hazard of program termination. Conclusion: While responses/sanctions (including incarceration) are a component cited in the Defining Drug Courts: The Key Components, findings indicate incarceration, particularly within the first 30 days, may hinder an individual's rehabilitative progress by increasing the hazard of program termination. These findings underscore that incarceration as a sanction be utilized sparingly; the Best Practice Standards implores the use of incarceration when the individual is an immediate public safety risk or after other consequences have been ineffective.

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"Impact of Medicaid supportive housing health home program on health care utilization for people living with HIV/AIDS" (HD08) Sarah Forthal, Sugy Choi, Rajeev Yerneni, and Charles Neighbors Lead author affiliation: Center on Addiction, 485 Lexington Ave, New York, NY 10017, USA Correspondence: Sarah Forthal (sforthal@centeronaddiction.org) Addict Sci Clin Pract 2020, 15(Suppl 2):A32 Background: Unstable housing among people living with HIV/ AIDS (PLWHA) has been consistently linked to poor HIV-related care engagement. Chronic comorbidities such as substance use disorders (SUDs) are common in this population and may further complicate treatment engagement, leading to poor clinical outcomes. Between 2012 and 2018, the New York State (NYS) Department of Health implemented a pilot supportive housing program for eligible clients in Medicaid Health Homes (HH), a comprehensive care management program for individuals with chronic conditions. The Health Homes Supportive Housing Pilot (HHSP) provided long-term supportive housing services to HH-enrolled, chronically homeless PLWHA. We assessed the impact of HHSP on health care utilization (outpatient services, emergency department (ED) visits, and hospitalizations). Methods: We analyzed monthly longitudinal data consisting of linked HHSP data and administrative data from NYS (excluding New York City) between 2012 and 2017. We used time series analysis to examine health care utilization as a function of HHSP enrollment, controlling for demographic variables and comorbid diagnoses. HHSP by SUD interactions were assessed using the cross-product term. Results: The final sample included 250 HHSP-enrolled PLWHA. The most common comorbid diagnosis was SUD (57.2%). Those with at least 6 consecutive months of HHSP had 20% higher odds of using an outpatient service, 19% lower odds of visiting the ED, and 24% lower odds of being hospitalized compared to those with less. The outpatient interaction between HHSP and SUD was positive and significant (p = 0.012). Conclusion: HHSP was effective in decreasing the likelihood of ED visits and hospitalizations while increasing the likelihood of outpatient visits for a group of unstably housed PLWHA. The increase in outpatient visits was larger among those with SUD. These findings suggest that supportive housing may promote better medical management by increasing outpatient visits among chronically homeless PLWHA with SUD.

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"Implementing a peer recovery coach-delivered behavioral intervention to support engagement in substance use treatment from a community setting in Baltimore city" ( Background: Low-income, ethnoracial minorities disproportionately experience poor substance use (SU) treatment outcomes and need support to increase engagement and retention in treatment. Peer recovery coaches (PRCs), individuals with lived experience of SU and recovery, can reach individuals from community settings to support engagement in care. The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of a PRC-delivered behavioral intervention to reduce problematic SU and support engagement in SU treatment from a community-based setting. Methods: This study took place at a community resource center serving unstably housed and low-income individuals. We piloted a PRCdelivered weekly, eight-session behavioral activation (BA) intervention designed to increase engagement in SU treatment by increasing substance-free positive reinforcement. We recruited adults with moderate-to high-risk problematic SU interested in harm reduction or SU treatment and not currently enrolled in SU treatment. A structured feasibility/acceptability assessment was administered at the end of study participation. Results: The PRC linked eight guests to SU treatment over 6 months based on individual preferences and needs (e.g. inpatient or outpatient program; medication for opioid use disorder). Current SU included: opioids (n = 5), crack/cocaine (n = 5), alcohol (n = 6), cannabis (n = 3), and sedatives (n = 1). Seventy-five percent of participants Addict Sci Clin Pract 2020, 15(Suppl 2):35 reported polysubstance use. Two participants were lost to follow-up before initiating BA sessions. Four participants completed all eight BA sessions, one participant discontinued after four sessions, and one participant discontinued after three sessions. All participants (n = 6) reported decreases in SU and five participants remained in treatment at the time they ended the intervention. Overall intervention acceptability and perceived feasibility were high. Conclusions: Findings suggest a PRC-delivered intervention in a community setting is feasible to engage individuals not otherwise connected to clinical care and acceptable to participants. Future research should examine the efficacy of PRC-delivered BA to reduce SU and support retention in treatment. Background: Addiction treatment organizations that integrate medical/behavioral healthcare at the same geographic location may reach a broader group of patients than traditional programs and deliver integrated care to a high-need, high-risk population. This study examined outcomes for clients experiencing combinations of homelessness and traumatic experience in one of the largest integrated care addiction treatment providers in Massachusetts, Casa Esperanza, Inc. Methods: Interviews were conducted with participants in Casa Esperanza's Comprehensive Integrated Treatment Approach (CITA) project (SM060845-0) at intake and 6-months. The analysis here is based on 199 participants (63%) with data at both time points. We examined a set of six dichotomous indicators indexing different aspects of health and well-being (employment, illegal drug use, anxiety, depression, health, and pain) and formed a summary index score by summing the six indicators at each timepoint. To examine change by homelessness and traumatic experience we formed a categorical variable with three levels: (1) not homeless and did not report traumatic events that resulted in their feeling emotionally or physically harmed or threatened, (2) either homeless or reported traumatic experiences, both homeless and reported traumatic experiences. We regressed followup index score at follow-up on the baseline value, the homeless/ trauma measure, and demographic covariates. Results: The mean number of domains positively endorsed increased in all three groups between baseline and follow-up, indicating positive change over time. The group that was homeless and had experienced traumatic events started lower and improved less over time, controlling for baseline starting place. Conclusion: Homelessness and traumatic experience are important factors in shaping how patients interact with, and benefit from, addiction treatment programs. Background: The present study examines disparities in Latino subgroups' completion of substance use disorder (SUD) treatment. Latinos represent the largest minority group entering SUD treatment in the United States, yet there is scant research specific to their performance in SUD treatment programs. Since Latinos are the most likely uninsured minority group, we tested the role of programs' acceptance of Medicaid payments in reducing disparities. Methods: We analyzed client and program data from 122 publicly funded SUD treatment programs across Los Angeles County in 2010, 112 programs in 2013, and 105 programs in 2015. These data were merged with information regarding 38,171 adult clients from all three time periods, of whom we selected Mexican Americans (32%), Cubans (0.3%), Puerto Ricans (0.6%), other Latinos (8.6%), and non-Latino Whites (58%). Multilevel logistic regression was used to examine program and client level factors associated with Latino subgroups and White differences in treatment completion. Results: Mexican Americans had the lowest Medicaid coverage, attended programs of lower quality, while reporting lower levels of mental illness. Mexicans were the only Latino subgroup that reported disparities in treatment completion. Conclusions: Implications of study findings can inform future research focused on differences among Latino subgroups to identify vulnerabilities and strengths of each group in positively responding to SUD treatment. Background: There are growing concerns over the increasing rates of electronic cigarette (e-cigarette) and marijuana use. It is especially important to investigate the impact on vulnerable populations including youth, of whom currently report the highest use rates (McMillen et al. 2015). Furthermore, it is crucial to address e-cigarette and marijuana use among ethnic minorities, who have been historically disproportionately affected. Individuals who identify as Latinx and/ or Hispanic are among the most rapidly growing ethnic group in the United States, so focusing on this group is particularly important. Saddleson and colleagues (2015) report e-cigarette use among Hispanic adolescents and young adults has increased in recent years. And, among some samples has surpassed the rate among Caucasians (Bostean et al. 2015;Leventhal et al. 2015). The national Youth Risk Behavior Surveillance System survey reports 42.1% of Hispanic youth have used marijuana at least once, and 24.4% reported using marijuana within the month before completing the survey (King et al. 2015). Methods. We compared use trends reported by our Spanish and English callers (parents or loved one) during a phone call with our Helpline Specialists. Results: For both English and Spanish callers, a child/loved one struggling with ongoing substance use was reported as the most common concern. In addition, a caller's child/loved one's age fell within the range of 12-28 years. Conclusion: As the rate of Latinx/Hispanic youth continues to grow in the United States, understanding factors that impact substance use among these youth is imperative. Prevention and treatment efforts should incorporate the diverse backgrounds and experiences of this ethnic minority group.

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Background: Access to medication for opioid use disorder (MOUD) is essential for improving health outcomes and reducing HIV and hepatitis C virus infections. This study aims to demonstrate how varying geographic distributions of MOUD resources, reflecting different dimensions of equity, may impact health outcomes among people who inject drugs (PWID). Methods: We evaluated three MOUD interventions (Methadone, Naltrexone, Buprenorphine) using different scenarios of varying levels of social and spatial health inequity in HepCEP, a validated agent-based model for Hepatitis C Elimination among the PWID population in Chicago and surrounding suburban areas. Specifically, we used the existing data from the synthetic population and infrastructure within the HepCEP model to newly apply MOUD interventions to model behaviors of PWID agents. To approximate potential access to resources, we calculated distance to the nearest MOUD provider using 2019 locations from the Substance Abuse and Mental Health Services Administration. We developed several hypothetical distributions of physical MOUD locations to reflect spatially random (i.e. equally distributed) and need-based patterns, and explored how different distributions of MOUD influences the MOUD intervention effects. Results: The MOUD interventions are designed to reduce or stop the frequency of injection activities, thereby disrupting the PWID networks within HepCEP, which in turn reduces hepatitis C transmission. However, our results showed that different spatial distributions of MOUD resource locations can lead to substantially different MOUD intervention effects on the behaviors of PWID and their downstream health outcomes. For example, with MOUD locations equally distributed through the area, the average treatment duration for Methadone would increase in 60% of zip code areas, and the average new chronic infection rate would decrease by 33% of areas by 2030. Conclusion: A spatial perspective is essential to understand the MOUD treatment heterogeneity that reflects the complex factors underlying social and spatial health inequity. Background: The Medicaid expansion has provided an opportunity to eliminate racial and ethnic disparities in treatment access and engagement in addiction health services (AHS) in the United States. By implementing public insurance coverage and delivering coordinated mental health and HIV testing, high capacity treatment programs may eliminate disparities in wait time and retention. High capacity programs in this study accept Medicaid payments and have high levels of director leadership and staff readiness for change. In this IRB approved study, we examined the extent to which program capacity leads to higher implementation of coordinated care and in turn increased treatment access and engagement among Latinos and African Americans comparing pre-and post-Medicaid expansion. Methods: We analyzed publicly available multi-year data from clients and programs at four points. We analyzed two waves during pre-expansion in 2011 (N = 115 programs, n = 11,526 clients) and 2013 (N = 111 programs, n = 18,789 clients), and two waves during postexpansion in 2015 (N = 106 programs, n = 17,339 clients) and 2017 (N = 94 programs, n = 16,191 clients). We relied on two path analyses to test differences between pre and post expansion on days to enter treatment (wait time) and days in treatment (retention), as well as mechanisms of change (coordinated care). We compared two multiple group negative binomial regression models to test race/ethnicity as moderators and coordinated care as mediating mechanisms. Results: Compared to pre-Medicaid expansion and white clients, Latinx and African Americans reported shorter wait times to enter care in high-capacity programs post-expansion. African Americans' retention was longer than whites in high-capacity programs post-Medicaid expansion. Additionally, receipt of HIV testing and coordination of mental health services played an indirect role in the relationship between high capacity programs and shorter wait time. Conclusion: Medicaid expansion played a significant role in eliminating disparities in treatment access and retention in AHS. Program leadership, readiness for change and Medicaid acceptance are important capacity factors to implement coordinated mental health and HIV testing and increase treatment access among minorities. Future research should consider these program capacity factors to implement other public health services (e.g., COVID-19 testing) to mitigate the disproportionate impact of the pandemic on minority communities. Surveys assessed socio-demographics (age, gender, race, education, community), substance use, depression and anxiety symptoms, trauma history and symptoms, recovery support, and barriers to treatment (e.g., childcare, work, housing, transportation, legal obligations, mental health). Descriptive statistics were used to examine individual barriers and a multivariate linear regression was calculated to assess predictors of greater cumulative barriers. Results: Geographic and logistical issues were the most commonly endorsed barriers, with over one-third reporting challenges related to their work schedule (35%), distance from home to treatment (34%), and transportation (34%). Past year opioid use (B = 1.73, p = 0.017) and more severe mental health symptomology (B = 0.23, p = 0.017) were associated with greater numbers of barriers. Greater levels of recovery support were associated with fewer barriers (B = − 0.23, p = 0.001). No associations were found for demographic variables. Conclusion: This study adds to the limited research on barriers to methadone treatment for clients in rural and small metropolitan communities. Individuals with more recent opioid use reported a greater number of barriers, suggesting barriers may be more substantial early on. Clients experiencing more depression and anxiety symptoms may be more vulnerable to treatment dropout, as evidenced by greater endorsement of barriers. As social support emerged as a potential protective factor against cumulative barriers to treatment, efforts to enhance family and peer support should be explored as adjunctive services to medication treatment.

Methods:
We evaluated whether a state dataset that tracked admissions and discharges from all public and private substance use disorder (SUD) treatment programs (DAANES; MN DHS 2020) could quantify the CoC for an American Indian tribal nation in MN. Analyses were restricted to American Indian individuals who were affiliated with a specific MN tribe, were admitted to or discharged from SUD programs in counties located within the tribal nation between 2017 and 2019, and reported opioids as their primary substance of use at admission. We evaluated whether the DAANES data could quantify the CoC steps, including those (1) at risk for OUD, (2) diagnosed with OUD, (3), who received medications for OUD, (4) retained in OUD treatment, and (5) who achieved OUD recovery. Results: Of 614 admissions with identified opioids as the primary substance, 390 (63.5%) had moderate/severe OUD diagnoses (direct measure of CoC step 2). A majority (424 admissions; 69.1%) had medications for OUD planned as part of treatment, usually buprenorphine (indirect measure of CoC step 3). Limitations: Step 2 lacks people whose primary substance was another non-opioid drug but still had OUD; people with repeat admissions are counted multiple times; step 3 only indicates planned medications, not whether medications were prescribed or taken.

Conclusions:
The DAANES data can provide some information about the CoC for AI/AN communities, including direct information about step 2 and indirect information about step 3. Additional data sources are needed to more adequately measure population-level OUD risk, treatment engagement, and recovery in tribal nations. Background: One in five individuals with opioid use disorder (OUD) receive medication treatment for OUD (MOUD). People receiving MOUD have lower risk of all-cause and overdose mortality. Black and Hispanic patients are less likely than white patients to initiate and continue MOUD, and racial disparities in MOUD remain largely unexplained. This study examines whether the relationship between race and initiation in MOUD is changed by contact with healthcare, human services, and criminal justice systems. Methods: We used data from the Allegheny County Data Warehouse, which links person-level data from several of the county's programs, including Medicaid, two court systems, the county jail, housing, and other social service programs. We examined the proportion of enrollees who initiated MOUD in the 180 days after an index OUD diagnosis. Results: In Allegheny County, Pennsylvania, Black Medicaid enrollees with opioid use disorder are one-third less likely to start medication treatment than white Medicaid enrollees (26.7% vs. 43.0%, p < 0.001). We were able to explain approximately 25% of the difference by race in initiation of MOUD. Visits to the emergency department explained much of the variation. In a sensitivity analysis, days in jail also explained some of the racial differences in initiation. Conclusion: Factors unrelated to the need for MOUD may impact initiation of MOUD and may explain variation by race. Our findings support current efforts to develop programs focused on initiation of MOUD in acute care facilities and criminal justice systems to improve rates of treatment overall and to reduce racial disparities. Background: Social support from family, friends, and others promotes retention in treatment, longer abstinence, and other positive outcomes for those in substance use treatment. Social support is especially critical during methadone treatment for opioid use disorder, due to stigmatization of this treatment modality (Cooper & Nielsen 2017). Little is known about social support for individuals receiving methadone in rural and small urban communities. This study examines factors associated with social support among adults receiving methadone treatment from a healthcare provider serving rural and small urban communities in Michigan. Methods: Adults (N = 267) were recruited at a methadone clinic to complete a web-based survey. Social support was assessed with the Social Support for Recovery (Laudet et al. 2000) and Friends' Support for Recovery (Humphreys et al. 1999) scales. Multiple regression was used to examine the association between social support and demographic variables, substance use, and stigma/shame (e.g. feelings of shame related to receiving methadone, frequency of hearing negative comments about methadone). Results: The sample was 59.6% female, 40.4% male; 85.0% White, 15.0% person of color. Mean age was 38.51 years (SD = 9.95). Half (48.3%) misused opioids in the past year. Male gender, feelings of shame, and the frequency of hearing negative comments about methadone were inversely associated with recovery-specific support. Past-year shame and the frequency of hearing negative comments about methadone were inversely associated with support from friends. Conclusions: Clients with stronger feelings of shame and who more frequently heard negative comments about methadone may also have lower levels of social support. These clients may be particularly vulnerable and need additional supports to maintain recovery. Interventions designed to enhance social support among individuals in methadone treatment may want to address shame and internal stigma. Those with higher levels of shame may benefit from interventions that address this feeling. Background: Despite national attention surrounding the opioid epidemic, recent reports suggest increases in methamphetamine use point to a "twin epidemic." There is evidence of widespread methamphetamine use among opioid-involved individuals, yet little is known about high-risk populations who use both methamphetamine and opioids. Given this limitation, the current study examines substance use and basic needs among mothers with co-occurring methamphetamine and opioid use who receive public assistance. Methods: Assessment data were collected from methamphetamine and opioid-involved mothers receiving public assistance in Kentucky (N = 2701) between July 2011 and June 2019. Participants were categorized into groups based on whether they reported only methamphetamine use (n = 616), only opioid use (n = 1660), or both methamphetamine and opioid use (n = 425) in the past 3 months. ANOVA and logistic regression were used to explore differences in demographics, substance use, and basic needs. Results: Overall, more than one-third (38.5%) of participants reported using methamphetamine in the past 3 months, and, on average, were 30 years old with 2 children, mostly white (94.8%), unmarried (83.9%), unemployed (80.1%), and had completed high school (66.8%). Mothers who used both methamphetamine and opioids were more likely to be unemployed, live in a non-metropolitan community, have an incarceration history, and self-reported more days of mental health problems and pain. They were more substance-involved, more likely to have recently injected drugs, and reported experiencing difficulties related to a wider variety of basic needs in the past 3 months, such as transportation and housing. Conclusion: Results suggest a high prevalence of methamphetamine use, while highlighting distinct differences related to methamphetamine and opioid involvement among mothers receiving public assistance. Implications for treatment policy and prevention include the importance of thorough assessments and intervention services that address the unique needs of mothers with co-occurring methamphetamine and opioid use who receive public assistance. Limitations include data collection in a single rural state. Background: Middle Atlantic states have been hard hit by addictive disorders, conditions that co-occur with infectious diseases and mental health disorders. Thus, a comprehensive array of addictionrelated treatment services is warranted. However, studies have yet to assess the availability of addiction-related treatment services and disparity patterns in the Middle Atlantic. Our objectives were to examine disparities between states and conduct urban-rural comparisons in the division and within states. We hypothesized rural disparities, and due to their rural composition, disparities for Pennsylvania and New York (compared to New Jersey). Methods: We extracted data (May, 2020) from national directories (SAMHSA, CDC, NCPG) and calculated per-capita county-level availability statistics for seven addiction-related treatment services (opioid treatment programs; non-OTP substance use facilities; certified gambling counselors; HIV, HCV, HBV specialty and non-specialty facilities; mental health facilities). RUCCs categorized urban (RUCCs = 1-3) and rural (RUCCs = 4-9) counties. Analyses included one-way ANOVA and non-parametric tests. Results: Of the 150 Middle Atlantic counties (PA = 67; NY = 62; NJ = 21), 36.0% (n = 54) were rural. In state comparisons, PA demonstrated disparities for facilities to treat HIV, HCV, and HBV (vs. NY or NJ) (Ps < 0.01). No additional state disparities were identified. Urban-rural disparities were revealed for each addiction-related treatment service. Rural counties experienced disparities for OTPs, certified gambling counselors, and facilities to treat HCV, HBV (Ps < 0.001), and HIV (P < 0.01). By contrast, urban counties demonstrated disparities for non-OTP substance use (P < 0.001) and mental health facilities (P < 0.01). State analyses demonstrated similar patterns, with more pronounced rural disparities in PA. Conclusion: This analysis highlights nuanced availability of addiction-related treatment services in the Middle Atlantic. In line with predictions, rural county disparities were consistently demonstrated, though urban county disparities were identified. Service expansion efforts for rural counties, particularly in PA, are urgently needed. Background: Severe maternal morbidity and maternal mortality are increasing in the U.S. Reasons for the increase in severe maternal morbidity are not well elucidated, though the trend is not fully explained by increasing maternal age. Prior studies have suggested that the increase of chronic disease burden in pregnancy may explain the rise in severe maternal morbidity. However, the extent to which substance use disorders may contribute to the risk of severe maternal morbidity is unknown. We aim to determine the independent association between substance use disorders in pregnancy and risk of severe maternal morbidity in the United States. Data and Study Population: National Inpatient Sample, nationally representative sample of U.S. hospital discharges, 2003-2016. We included females ages 18-55 years of age with a hospitalization for labor and delivery. Methods: We conducted a retrospective analysis of a weighted 53.4 million delivery hospitalizations. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was a binary measure indicating a severe maternal morbidity, according to the CDC algorithm including 21 indicators; with and without blood transfusion. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 years vs > 34 years). Results: Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95% CI 1.41, 1.61, > 34 years: aOR: 1.17; 95% CI 1.00, 1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95% CI 1.80, 2.0, > 34 years: aOR: 1.85; 95% CI 1.66, 2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity. Results were consistent when considering severe maternal morbidity with and without blood transfusion. Conclusion: Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States. Addict Sci Clin Pract 2020, 15(Suppl 2):35 Background: Individuals cycling in and out of the criminal justice system disproportionately experience substance use disorders that result in a multitude of negative outcomes. While there is a growing body of research examining substance use trajectories, there are still large gaps in our knowledge, particularly among probationers. Using data from the Motivational Assessment Program to Initiate Treatment (MAPIT) multi-site, randomized controlled trial funded by NIDA (R01 DA029010-01), the current study examines the substance use patterns among individuals while on community supervision, with attention to the factors that predict membership into those substance use groups and how those substance use groups may predict re-arrest. Methods: Self-report baseline and follow-up surveys and administrative data for 275 individuals are used to conduct group-based trajectory analysis, logistic regression, and survival analysis. Timeline Follow-Back data collected for 180 days post-baseline measured any illicit substance use and/or binge alcohol use, while re-arrest between 6-and 18-months post-baseline was captured dichotomously and as days until event from administrative records. Results: Six groups of substance users emerged from the data: abstainers, late-increasing, low-moderate, increasing, decreasing, and high user groups. The number of probation contacts, formal treatment attendance, number of arrests, and housing in a non-controlled environment were the time-varying predictors related to group membership, while risk-taking, family and peer drug use, initiating substance use under the age of 16, and severity of drug disorder were time-stable risk factors for group membership. Despite the distinct substance use patterns that emerged, the pattern of substance use did not predict later re-arrest among this group of individuals on community supervision. Conclusion: Despite the distinct substance use patterns that emerged, the pattern of substance use did not predict later re-arrest. The patterns of substance use provide insights that could support interventions and justice controls to serve both health and justice goals. Background: Successful engagement with and retention in medication treatment for opioid use disorder (MOUD) is an important focus in the fight against the opioid crisis. Gaps in OUD care point to a need for improved understanding of factors that affect MOUD outcomes and how barriers may act as syndemic factors, compounding one another's effects. This study used qualitative methods to solicit feedback about barriers to retention and successful treatment outcomes in MOUD. Methods: This study was conducted at a community-based drug treatment center that serves a low-income, minority population. We recruited patients and staff as well as peer recovery coaches who work in OUD recovery across Baltimore City. Semi-structured interviews and focus groups asked about factors that influence MOUD treatment outcomes and how barriers co-occur and interact. We used thematic analysis to examine themes pertaining to our research questions and two independent coders coded each transcript based on identified themes.

Results
: Participants (n = 20) had a mean age of 48.4 (SD = 10.0), 70% male, and 60% Black or African American. Mean reported age of first drug use was 17.7 (SD = 5.1). Staff and peer recovery coach (PRC) participants (n = 12) had a mean age of 49.2 (SD = 0.7), were 42% male, 75% Black or African American, with an average of 9.6 years working in substance use treatment. Barriers described by participants fell into four overarching but cross-cutting levels: individual/self, social/ interpersonal, institutional/structural, and community/environmental. Participants described co-occurrence of these barriers as fueling one another and having a disastrous effect on treatment outcomes. Conclusions: Understanding barriers to successful MOUD outcomes experienced by this vulnerable population and considering the synergistic effect of these barriers may assist with identification and promotion of the types of interventions needed to effectively and efficiently mitigate their impact. Background: Stigma, or systemic devaluing of groups based on features that distinguish them from societal norms, is common for persons with substance use disorders. For people who inject drugs (PWID), stigma may influence experiences navigating care for hepatitis C as well as care for other pressing health needs. Methods: As part of a broader study focused on developing a community pharmacy model of medication delivery, we conducted semi-structured qualitative interviews to understand PWID's careseeking experiences. Participants were recruited from Seattlearea community organizations and eligible if they had recent (≤ 3 months) injection drug use and hepatitis C. Interviews were transcribed and analyzed using a Rapid Assessment Process, where two independent coders summarized learnings using structured templates and iterative review to identify themes. Here we report emergent themes specific to experiences of stigma. Results: Among 40 participants, 65% were male, 53% were White, and most (80%) were not stably housed; mean frequency of injection use was daily. Participants reported internalized stigma, which, when paired with the interpersonal stigma (e.g. stigmatizing language and behaviors) enacted by care team members, created barriers to how PWID express their care preferences and felt heard by providers. As PWID navigated care, their status as an active user of drugs was used to control and sometimes coerce their access to services (for instance through court-mandated treatment), further minimizing the value of individual preferences for care and reinforcing perceived stigma. Consequently, the experience of stigma discouraged PWID from seeking needed care. Conclusions: This study underscores the pervasive role stigma has throughout PWID's experiences with healthcare and its impact on PWID's ability to navigate the care they need. Multilevel interventions that target the individual, interpersonal, community, and structural levels of stigma associated with injection drug use may be needed to mitigate negative impacts on PWID health outcomes. Background: Little is known about the trends in gabapentin utilization in the Medicare population. Our goal was to characterize gabapentin utilization among Medicare beneficiaries overall, and among specific clinical [disabled, chronic pain (CP), mental health disorders (MHD), substance use disorders (SUD), seizures, postherpetic neuralgia, neuropathic pain and opioid or/and benzodiazepine users] subgroups. Methods: We conducted a retrospective longitudinal analysis using a 5% sample of 2006-2015 Medicare data. We included fee-for-service beneficiaries with ≥ 1-month coverage during each year within our study period. Clinical conditions were defined based on a diagnosis of CP (back, neck, joint, head or chronic pain), MHD (anxiety, depression, personality disorders, mood disorders, adjustment disorders, and attention deficit hyperactive disorders), SUD (alcohol, opioid or non-opioid) and neuropathic pain. Opioid or/and benzodiazepine utilization was defined as ≥ 2 prescriptions for either/ both medication(s) in each calendar year. We compared the annual prevalence of gabapentin utilization overall, and among clinical subgroups. Results: The study included 9.3 million person-years between 2006 and 2015. The percentage of individuals who utilized gabapentin increased from 5.38% (95% CI 5.33-5.42) in 2006 to 11.68% (95% CI 11.62-11.75) in 2015 (p < 0.0001), an increase of 112%. All subgroups experienced increased gabapentin utilization between 2006 and 2015; however, the increase in gabapentin utilization was highest among disabled individuals (8.15% to 18.48%), opioid users (13.64% to 27.48%) and those with SUD (12.17% to 28.39%). Gabapentin utilization remained high among benzodiazepine users (19.03% in 2013 to 21.58% in 2015) and opioid and benzodiazepine users (28.05% in 2013 to 31.82% in 2015.) Conclusion: Gabapentin utilization has increased significantly over the years, especially among high risk sub-groups. Given emerging evidence concerning gabapentin's association with respiratory depression, it is essential we comprehensively examine its ongoing utilization, especially among those who may be potentially more vulnerable to these adverse effects. Background: Military veterans are disproportionately represented in United States (U.S.) jails and prisons, with nearly 10% of current inmates being veterans. Veterans' criminal justice involvement is often precipitated by underlying mental health and substance abuse that are connected to their military service. Veterans' treatment courts are the judicial response to a need for more coordinated provision of mental health and substance abuse services to veterans involved in the criminal justice system. Modeled after drug courts and mental health courts, veterans treatment courts are a judicial innovation that aim to honor the service of veterans by providing them an alternative to incarceration. Methods: There are currently 551 veterans' treatment courts in 42 states throughout country, including five in Kentucky. This exploratory descriptive study uses Andersen's healthcare utilization model and a social control theoretical perspective as a framework to examine veterans' treatment court outcomes from a sample of participants (N = 58) in Kentucky. Univariate and bivariate analyses were used to provide a description of the sample and to examine relationships between personal characteristics and during-program occurrences and the outcomes of program completion and criminal recidivism. Results: Gender, sanctions, drug screens, and treatment sessions each had a significant association with program completion, and both age and housing status had a significant association with recidivism. Conclusion: Findings for each outcome variable are discussed, along with possible explanations, as well as limitations of the study, implications of this research for social work practice, and suggestions for future research.

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"Assessing overdose education and naloxone distribution within syringe service programs throughout the United States" Background: Syringe service programs (SSPs) have been a linchpin for public health efforts such as HIV and HCV prevention for people who use drugs (PWUD), and SSPs have led efforts for community-based overdose education and naloxone distribution (OEND). SSPs are ideal venues to deliver OEND for PWUD, with staff who excel in providing culturally appropriate services and delivery systems designed to reach people where they are. We describe phases of OEND implementation within SSPs and assess predictors of SSP-based OEND penetration throughout the United States. Methods: In collaboration with the North American Syringe Exchange Network and Harm Reduction Coalition, we surveyed all known SSPs in the United States in 2019. Out of the 342 known SSPs operating, 266 (77%) responded to the online survey. We utilized negative binomial regression to assess predictors of SSP-based OEND penetration (i.e., number of naloxone doses distributed), adjusting for opioid overdose deaths in the region. Results: Regarding OEND implementation phases, 3% of SSPs were exploring OEND implementation, 3% were actively preparing for OEND implementation, 28% implemented OEND for < 12 months, and 66% had implemented OEND for ≥ 12 months. In the prior year, 237 SSPs reported distributing 710,232 naloxone doses, including refills, to 230,506 people. We found that penetration of SSP-based OEND varied substantially by census division (p < 0.001). In addition, we found that proactive naloxone refill systems (adjusted Incidence Rate Ratio (aIRR = 2.77; p = 0.002) and higher levels of community support (aIRR = 2.54; p = 0.039) were associated with significantly higher rates of naloxone doses distributed. SSPs located in regions with larger numbers of opioid overdose deaths did not have significantly higher levels of naloxone distribution. Conclusions: While our results showed high levels of OEND integration within SSPs in the United States, OEND penetration varied substantially across census divisions, and substantial opportunity existed for improving penetration of SSP-based OEND. Public health initiatives to reduce opioid overdose deaths should increase investments that support and scale-up SSPs and SSP-based OEND services throughout the United States. Background: Text messaging is a popular and widely used smartphone feature. Research demonstrates the effectiveness of text messages in supporting individuals with chronic diseases and mental health conditions to better manage their symptoms. Following this trend, recent studies found text messaging helped individuals with substance use disorders (SUD) to increase engagement in treatment and/or recovery support services, receive educational resources, and learn to manage craving and negative thoughts/moods. Unfortunately, SUD treatment/recovery support providers' uptake of text messaging has been slower than other health providers. Methods: A series of online learning and consultation strategies were implemented to increase uptake of text messaging by SUD treatment/recovery support providers. First, a step-by-step guide was created to help providers use text messages to enhance and expand the reach of their services. Next, the guide was used to structure a 4-session virtual initiative called Text Reminders to Assist Clinical Effectiveness and Recovery (TRACER), designed to teach providers how to: set up a texting sequence that supports treatment flow; use a texting provider to send messages that support the treatment sequence; send texts that are positively-framed, direct, and personalized; ensure the messaging strategy is compatible with legal/ethical guidelines; and use different formats for texting sequences. Third, at the end of the 4-sessions providers had an opportunity to have a 1-h individual consultation session to discuss implementation of text messaging at their agency. Results: Responses were 100% positive regarding the overall TRACER experience. Quantitative and qualitative findings will be presented about the usefulness of the texting guide, format/content of the virtual sessions, and successes/challenges to implementing text messaging. Conclusion: A brief online learning and consultation series can be used as a vehicle to boost SUD treatment and recovery support providers use of technology and serve as a vehicle to intervention adoption. Background: Rates of opioid use disorder (OUD) have risen at an alarming rate, with overdose deaths peaking nationally in 2017. More than 200,000 individuals with an OUD are involved with the criminal justice system yearly. Within the first 2 weeks post-release, unintentional fatal overdoses spike, as individuals lose their tolerance during incarceration. Medication for opioid use disorder (MOUD) has been shown to significantly decrease relapse and recidivism, while increasing retention in treatment. In 2016, upon the introduction of the Governor's Overdose Prevention and Intervention Task Force, Rhode Island (RI) became the first state to implement a state-wide medication assisted treatment (MAT) program within the correctional system, offering all three FDA-approved MOUD to incarcerated individuals. Methods: Linkage to MOUD treatment post-release has been expanded into the community, leading to a significant decrease in statewide fatal overdose incidents post-release in RI. The program aims to target individuals who are at even higher risk for relapse/overdose post-release, providing continuity of treatment and support for clients as they are reintroduced into the community. This program partners Brown University, CODAC Behavioral Healthcare, RI State Police, RI District Court, and RI Department of Corrections to increase adherence to MAT through an intensive post-release support protocol, implemented by a multidisciplinary outreach team. A clinician, a member of local law enforcement, and a peer navigator collaborate to provide case management, recovery support services, and referrals. Results: We have enrolled 142 individuals, and provided resources including transportation, client/family emotional support, and referrals to behavioral health providers and MAT programs. The multidisciplinary nature of each unit has allowed clients to bypass traditional barriers in continuity of treatment. Conclusion: By ensuring access to MAT for criminal justice-involved individuals, levels of relapse/overdose are expected to decline, leading to lower crime, more intact families, increased employment, and improved community engagement. Background: Experimental evidence supports the Implementation & Sustainment Facilitation (ISF) strategy as an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy for improving implementation of a motivational interviewing-based brief intervention for substance use within HIV service organizations. However, beyond the need to identify effective implementation strategies is the need to understand the mechanisms of change for implementation strategies. This study explored the extent to which changes in implementation climate and readiness were mechanisms of change for the ISF strategy. Methods: Thirty-nine HIV service organizations and their staff (n = 78) were randomized to receive the ATTC strategy or the ATTC + ISF strategy. Implementation climate (the extent to which implementation was expected, supported, and rewarded) and implementation readiness (the extent to which staff had the necessary training, knowledge, skill, and time for implementation) were assessed prior to randomization and after the project's implementation phase. Adjusted multilevel regression analysis was used to examine the extent to which the implementation effectiveness of staff could be predicted by changes in implementation climate and implementation readiness. Results: The ISF strategy remained a significant predictor of implementation effectiveness in all models. In addition, variation in implementation effectiveness was explained by changes in implementation readiness (β = 0.14, p = 0.02), but not by changes in implementation climate (β = 0.05, p > 0.05). Regarding the impact of the ISF strategy on these two putative mediators, the ISF strategy was found to have a significant impact on changes in implementation climate (β = 0.83, p = 0.004), but did not quite reach statistical significance regarding changes in implementation readiness (β = 0.65, p = 0.09). Conclusions: Evidence suggests the ISF strategy improved implementation climate and implementation effectiveness, yet neither implementation climate nor implementation readiness was able to be supported as a potential mechanism of change. in Arkansas implemented (e.g., guidelines, technologies), and what factors influenced their ability to implement and sustain these changes. Methods: We conducted semi-structured phone interviews with SUD program leadership (administrative and/or clinical leaders). Interviews are based on the Consolidated Framework for Implementation Research and focus on what changes programs are implementing, barriers and facilitators to implementation, and recommendations. Interviews were recorded and transcribed verbatim and are currently being thematically analyzed (preliminary analyses are presented). Results: We interviewed 29 leaders at 21 residential and outpatient SUD treatment programs. Preliminary analyses indicate that programs implemented similar infection control practices: COVID-19 screening at entry, use of masks, hand hygiene, and social distancing (including working from home, when possible). To limit contacts between different groups (clients, staff, visitors), residential programs also discontinued outside visitations and some capped admissions; outpatient programs discontinued group sessions or switched to telehealth and, when possible, switched individual sessions to telehealth (some continued in person, e.g. for client preference, drug screening). Key facilitators included grants/loans to help finance salaries, equipment, and service extension, looser regulatory restrictions (e.g. telehealth, prior approval), and good communication and coordination with other organizations (e.g., state agencies, partners, peers). Key barriers included limited access to supplies (e.g., masks, disinfectants), lack of rapid COVID-19 testing (particularly for clients entering residential treatment), limited capacity for social distancing, and negative employee and client responses (e.g., anxiety, quitting). Considerable uncertainty and concerns remain about sustainability of new practices, including long-term economic viability of SUD programs, and their ability to meet clients' treatment and support needs. Key recommendations include better access to supplies, rapid COVID-19 testing, telehealth continuation (including beyond the pandemic), and strengthened communication within and between organizations to enhance resilience of the SUD services system. Conclusion: This study provides an early insight into how SUD programs are responding to COVID-19. Future studies can quantify the extent/prevalence of identified themes and examine what strategies can help sustain the implemented changes. Background: Research has shown that attitudes such as pre-training anxiety, pre-training motivation, and perceived organizational support towards Evidence-Based Treatments (EBTs) predict learning and clinical use of EBTs. Learning is also influenced by perceived barriers-minimizing organizational and perceptual barriers to EBT implementation has demonstrably improved EBT training outcomes. Finally, differences in therapists' self-reported allegiance to various therapeutic orientations may impact the degree to which they engage in trainings for specific therapy frameworks like family therapy (FT). Methods: This study tested provider attitudes toward EBTs, allegiance to FT, and perceived barriers to delivering FT in predicting training uptake in terms of perceptions of training utility and rate of weekly training module completion. Training included weekly 20-min online training sessions in which therapists viewed and coded short videos exemplifying expert use of FT techniques. We hypothesized that stronger attitudes toward EBTs, greater allegiance to FT, and fewer perceived barriers to delivering FT would predict greater training uptake. Providers were a diverse group of frontline therapists treating adolescent behavior problems. Results: Multiple linear regression was used to assess the relation between attitudes toward EBTs, FT allegiance, and perceived barriers and participation in training activities. Results indicated therapists who endorsed more positive attitudes toward EBTs in terms of Openness to Innovation and Intuitive Appeal reported greater utility of the training system. Furthermore, allegiance to FT predicted a higher rate of training module completion. Contrary to hypotheses, attitudes towards Organizational Requirements, Perceived Divergence of Research-based Innovation, and perceived barriers to implementing FT did not significantly predict outcomes. Conclusion: Positive attitudes towards EBTs, and greater proficiency and allegiance to FT are important for FT training uptake. Providers treating adolescent substance use who are more open to trying new interventions and who endorse a stronger allegiance to FT may be more likely to engage in novel FT online video-based training opportunities. Background: Contingency management (CM) is an evidence-based behavioral treatment in which patients have the opportunity to earn motivational incentives for achieving treatment goals. One potential barrier to the successful implementation of CM in opioid treatment programs (OTPs) is negative provider attitudes towards CM. Training can potentially help improve the implementation of CM in OTPs, but the relationship between provider attitudes towards CM and responsiveness to training is not well understood. Using data from the first cohort of a multi-site type 3 hybrid trial, this study evaluates the relationship between CM knowledge and skills, as well as the extent to which providers' CM attitudes predicted both CM knowledge and skills after training. Methods: Thirty-nine treatment providers from eight OTPs completed a CM Attitudes survey, which assessed provider attitudes regarding the acceptability and effectiveness of CM. Providers then completed an 8-h CM training. After the training, 35 providers completed an 18-item CM Knowledge Test to assess their knowledge of CM principles and 30 providers submitted a CM session role-play to assess their CM skills. Results: Bivariate analyses supported the a priori hypothesis that there would be a statistically significant correlation between CM knowledge and skill (r = 0.50, *p* = 0.007). Multivariate regression supported the hypotheses that CM attitudes would predict both CM knowledge (b = 0.47, p = 0.005) and CM skill (b = 0.56, p = 0.002), even when controlling for providers' age and months of clinical experience. Conclusion: Providers with more negative CM attitudes were less responsive to CM training, suggesting that pre-training attitudes represent a novel training target. Providers with negative CM attitudes may benefit from customized training to address CM misconceptions. Overall, the study findings highlight the importance of considering counselors' attitudes when designing CM training in order to better address the barriers surrounding CM implementation. Addict Sci Clin Pract 2020, 15(Suppl 2):35 Background: Community-based pharmacies play a pivotal role towards improving opioid safety by dispensing naloxone, medications for opioid use disorder and selling nonprescription syringes for safe injection. This study explored pharmacist attitudes, knowledge, and experience in dispensing naloxone, providing buprenorphine and selling nonprescription syringes as well as the acceptability of a pharmacy-based training program, entitled RESPOND TO PREVENT, aimed at improving these three content areas to reduce opioid-related harms. Methods: Two online asynchronous focus groups were conducted with community-based chain pharmacists (n = 32) across Massachusetts, New Hampshire, Oregon, and Washington state. Eligible participants were those pharmacists who had completed the baseline assessment and online course. Each pharmacist participated anonymously for approximately 30 min across a 52-60 h window. Questions focused on prescriber support, policy impacts at the store, state, and federal level, experiences with pharmacy-based naloxone, and intervention implementation barriers and facilitators. Qualitative data analysis was conducted by a multidisciplinary team using an immersion-crystallization approach. Results: Five major themes were identified in the focus groups: (1) gaps in pharmacist and broader pharmacy team knowledge of opioid use disorder, pharmacy-based naloxone, buprenorphine and syringe safety and sales; (2) shifts in self-efficacy to initiate "tough" conversations with patients and counseling about naloxone using intervention materials; (3) attitude changes regarding the pharmacist's role as community caretaker; (4) practice changes to increase provision of naloxone and syringe sales; and (5) barriers to naloxone provision due to cost concerns and stigma towards people who use drugs. Conclusion: Community pharmacists across four states identified important knowledge, training, and stigma-related gaps. Results reflect rich and positive experiences of community-based pharmacists participating in the educational intervention and provide face validity for the content of the modules and intervention materials as a means of addressing identified gaps. Background: Research on adult learning, evidence-based practices adoption/implementation, and workplace learning shows that training alone rarely changes practice behavior. To align with these tenets, it was posited that a new training/technical assistance model linking training to other services (e.g., expert consultation, performance feedback, peer support, reminders, and case studies) could dramatically improve training outcomes. The new model, called Workwise, is an online series that provides participants interactive instructional/consultation activities, including Learning Extenders, which are brief text messages that include reminders, prompts, questions, and links to videos or websites to increase learning, retention, and skills. Methods: Each Workwise series is an online interactive training and consultation initiative on treatment/recovery-related topics. The series involves a higher level of learning intensity and commitment than other training formats and participants receive approximately four Learning Extender reminders each week. Participants complete prepost-follow-up web-based surveys to assess the technology-based training and the impact of the Learning Extenders on changing and/or enhancing their learning experience. Results: Overall, participants said the Learning Extenders were useful in reminding them to complete learning activities, keeping them engaged in the sessions, and helping them apply the materials. Most also said they would recommend using text messages in future trainings and that it was beneficial to their learning experience. Qualitative and quantitative data will be presented. Conclusion: Adding text-based Learning Extenders to a series of sequenced learning activities further enhances the training experience and improves training outcomes. Background: Contingency management (CM) is the most effective adjunctive treatment to medication for opioid use disorders, but its implementation in opioid treatment programs (OTPs) remains low. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) is a type 3 hybrid trial testing strategies to help OTPs implement CM. This poster reports process data from the project's first cohort of OTPs. Methods: Staff and patients from eight OTPs were cluster randomized to receive either the Addiction Technology Transfer Center (ATTC) strategy (workshop + feedback + coaching) or the Enhanced ATTC (EATTC) strategy, which layered in two additional strategies: Pay-For-Performance and Implementation Sustainment Facilitation. Consistent with the exploration, preparation, implementation, and sustainment (EPIS) framework, OTPs engaged in 5 months of preparation and 7 months of implementation. Results: Each OTP completed preparation activities and advanced to the implementation phase. During the preparation phase, 52 staff (28 ATTC, 24 EATTC) completed a baseline survey. Of those enrolled, 41 (75% ATTC, 83% EATTC) staff participated in a didactic CM workshop and 31 (54% ATTC, 67% EATTC) submitted a role play for performance feedback. During the implementation phase, each OTP sought to enroll 25 patients. Overall, OTPs in the ATTC condition recruited 88% of the target, while OTPs in the EATTC condition recruited 100%. Of the 58 CM session recordings submitted for feedback, 29 met the skills benchmark: 8 ATTC and 21 EATTC. Conclusions: Preliminary process data indicate that CM recruitment, training engagement, and session submissions were greater in the experimental EATTC condition, relative to the ATTC control condition. Next steps will include examining the impact of the EATTC strategy on (a) number of CM sessions implemented with patients, (b) reductions in patient's days of opioid use at follow-up, and (c) OTPs sustainment of CM during the 6-months post-implementation.
Background: Contingency management (CM) is an evidence-based practice for opioid use disorder (OUD) that enhances the provision of usual care (i.e. medication for OUD) through rewarding patients for achieving treatment goals. However, CM faces numerous barriers to successful implementation in opioid treatment programs. Health professional stigma toward individuals with OUD is one important barrier that may limit treatment providers willingness to implement CM. Methods: We assessed CM familiarity and implementation barriers and facilitators through qualitative interviews (N = 43) with treatment providers and leaders across 11 opioid treatment programs. De-identified interviews were transcribed and coded by two independent coders, with each coder completing half the interviews. A third coder coded 20% of the interviews to ensure inter-rater reliability and both a priori and emergent themes were analyzed. Results: Stigma toward individuals with OUD was prominent in the transcripts, with 86% of transcripts having stigmatizing language (i.e. "substance abuser," "clean/dirty," or "addict") or themes. Several emergent themes related to stigma were identified, including: (a) distrust of individuals with OUD; (b) infantilizing views; (c) belief that individuals with OUD don't deserve prizes; and (d) recognition of individuals with OUD having self-stigma and community-based stigma. Conclusion: These emergent themes highlight the importance of stigma as a key target for implementation strategies to facilitate sustained CM use in opioid treatment programs. Strategies to enhance CM and other evidence-based practice implementation in community opioid treatment programs likely need target multiple types of stigma (i.e. language, infantilizing views, and individual self-stigma) in order to facilitate effective scale up. Background: Describe the proposed design of and baseline data for a study using individualized prescribing portraits to reduce inappropriate initiation of prescription opioid analgesics to opioid naïve patients in primary care. Methods/design: A mixed methods cluster randomized controlled trial tests a quality improvement initiative on safer opioid prescribing in primary care. The monthly incidence of opioid initiation is the primary outcome and is estimated using administrative data from a Centralized Medication Monitoring Database in British Columbia, Canada. Opioid naïve patient status is defined as no opioid prescriptions in the past 6 months. Secondary outcomes include related health outcomes (e.g., hospitalization, emergency department visit), and the intervention experience among a purposive sample of physicians and patients. Communities are randomized by geographical location and physicians receive either an "early" portrait (intervention group) or "delayed" portrait (control group) 1 year later.

Results:
Between December 2018 and November 2019, a total of 5657 active family physicians initiated 139,145 opioid prescriptions to opioidnaïve patients. The mean monthly initiation rate was 2.05 prescriptions per physician. Majority of initiations were in the Lower Mainland regions of BC, also where the population is most concentrated, (46,456, 33% in the Fraser region), by prescribers who graduated between 1996-2010 (49,314, 49%), and had less than 10 visits per day (72,506, 52%). Conclusions: We identified high numbers of initiation of opioid prescriptions to opioid naïve patients at baseline. The trial will provide important information on the potential of a complex educational intervention to change policy and practice on initiation of prescription opioid analgesics. Background: Most people in the U.S. with co-occurring opioid use disorder (OUD) and serious mental illness are treated primarily in mental health settings and do not receive treatment for their OUD. In the current study, we conducted focus groups with staff working in public mental health outpatient clinics to explore organizational capacity challenges to implementing medication for OUD (MOUD). Methods: We conducted two focus groups (composed of medical/ supervisory staff or front-line clinical staff) at 8 publicly funded clinics (n = 108) in Los Angeles County selected for diversity and size. Focus groups were recorded and transcribed. Transcript coding was guided by Meyer et al. (2012)'s eight constructs of organizational capacity for public health. Results: Themes were largely consistent among the clinics. The most frequently mentioned capacity constraints were workforce, system boundaries, inter-organizational relationships, organizational culture, governance/decision-making, physical infrastructure and fiscal/ economic. Staff from 7 clinics perceived that they lacked training and expertise. Staff at 7 clinics reported their caseloads were heavy and more specialized staff were needed to address OUD. Staff at 6 clinics reported mixed messages about MOUD from leadership and within the organizational culture. Staff at 7 clinics reported challenges accessing substance use treatment resources in their community. Staff at 6 clinics perceived that few clients had OUD. Staff also described capacity constraints in physical infrastructure, such as lack of office space (3 clinics) or facilities for urine testing and MOUD delivery (5 clinics). Finally, staff at 4 clinics mentioned unclear billing procedures for OUD. Despite these barriers, participants were receptive to receiving more training and resources to implement MOUD. Conclusion: There are significant capacity constraints to implementing MOUD in public mental health clinics, highlighting the need to develop effective implementation strategies to address these gaps. is implemented in real-world treatment settings, it is implemented with poor adherence. The objective of this poster is to describe the development and implementation of CM Tracker, which was custom developed to serve the dual purpose of a research tool for standardizing the assessment of CM implementation and an implementation strategy (i.e., develop and implement tools for quality monitoring) to improve adherence. Methods: Funded by the National Institute on Drug Abuse, Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) is a type 3 hybrid trial testing strategies for helping OTPs and their staff implement CM. Beyond general implementation data, CM Tracker was designed to collect and store data specific to the escalating prizebased CM protocol being implemented as part of Project MIMIC. By providing simple inputs about CM sessions, OTP staff receive a userfriendly dashboard that provides visual information to support CM implementation with patients. Results: To date, 22 CM staff have used the project's CM Tracker for documenting the quality of CM implementation. Of the project's 188 patient participants, 162 (86%) initiated CM. Per data collected using CM Tracker, the median number of CM sessions implemented per patient was 7 (out of 12 possible sessions).

Conclusion:
The CM Tracker is an innovative tool that can simultaneously serve a research tool and an implementation strategy. Future research is needed to examine the extent to which OTPs sustain the implementation of CM, as well as examine the extent to which they develop their own tools for monitoring quality of CM implementation. Background: Following identification of technical assistance priorities for the opioid epidemic via a needs assessment survey of workforce members in Health and Human Services Region 10, the Northwest Addiction Technology Transfer Center (Northwest ATTC) embarked on corresponding provision of universal, targeted, and intensive technical assistance. Responsive efforts by this intermediary purveyor organization are ongoing, and include sponsorship of products and activities for local, regional, and national audiences. Methods: Iteratively developed by a multidisciplinary team, survey content included eight items on prevention, treatment, and recovery practices for opioid use disorder (OUD) rated on a five-point scale of importance (1 = Not At All, 5 = Extremely). A lone inclusion criterion for workforce respondents, recruited via the Northwest ATTC website, was employment as a health professional in HHS Region 10. Cumulative record of responsive products and activities over the subsequent 18 months was compiled by Northwest ATTC leadership. Results: In this workforce sample (N = 306), the three greatest priorities were treatment of OUD and co-occurring disorders (M = 4.47, SD = 0.73), clinical services for pregnant/parenting women with OUD (M = 4.39, SD = 0.88), and community-based OUD recovery support (M = 4.32, SD = 0.85). Generalized linear models confirmed this pattern as robust across the four HHS Region 10 states. As for responsivity to these identified priorities, Northwest ATTC has sponsored: (1) expositions and exhibits at state and regional conferences, (2) webinar presentations for regional and national audiences, (3) training workshops for local workforce groups, (4) online educational products, and (5) intensive technical assistance projects to support implementation of useful practices by partnering health agencies. Conclusions: Initial, survey-based needs assessment of a regional addiction workforce informed subsequent Northwest ATTC provision of universal, targeted, and intensive technical assistance to combat the opioid epidemic. This process may be informative to other intermediary purveyor organizations seeking to address workforce priorities in their locales. Background: Dentists are one of the highest prescribers of opioids. Several dental schools and state dental associations have made efforts to increase curricular offerings on opioid use disorder (OUD) and appropriate prescription of opioids. The purpose of this study was to conduct an environmental scan on the inclusion of OUD in postgraduate dental training. Methods: A 46-item self-administered online survey was sent to 265 dental postgraduate primary care [Advanced Education in General Dentistry (AEGD) and General Practice Residency (GPR)] program directors (PDs) in February 2019. The survey included questions on behavioral health content (BH), e.g. inclusion of OUD, importance of training residents on OUD, evaluation of resident competence and usage of the prescription drug monitoring program (PDMP). Results: We received 111 responses from GPR and AEGD PDs (42% response rate). The majority of the programs think it is important for residents to receive training (n = 97, 87%) in identifying OUD and knowing community and oral health resources to provide referrals (n = 97, 87%). Similarly, a majority (n = 95, 86%) of the respondents train their residents to identify OUD. While only 42% (n = 42) of the respondents evaluate students on BH in their curricula, a majority of those evaluated consider their residents competent in identifying OUD (n = 35, 83%) and knowing resources to provide referrals for the disorder (n = 36, 86%). Around 80% (n = 90) of the programs teach their residents to utilize the state's PDMP. Conclusion: It is encouraging that most PDs train their residents to identify OUD. Best practices need to be disseminated to increase uptake in programs that have not yet included OUD in their curricula and to utilize the state's PDMP program. Finally, evaluation of residents' competency to identify and refer their patients with OUD needs greater importance. Methods: During Spring 2020, the TTCs quickly shifted an entire continuum of T/TA offerings from primarily in-person to virtual delivery since policies implemented to mitigate COVID-19 spread, including stay-at-home orders and social distancing, prohibited in-person attendance. TTCs rapidly innovated to ensure that the workforce had access to virtual T/TA without disruption. Each TTC was surveyed about COVID activities and 41 responded: 13 ATTCs, 12 PTTCs, 10 MHTTCs; and 6 International. Results: Lessons learned in this shift to virtual T/TA service delivery will be highlighted including: using technology (expansion of videoconferencing platforms); promoting best practices for online learning (educating traditionally in-person trainers about virtual learning);creating downloadable products to augment/reinforce learning (fact/tip sheets); sponsoring online events to gather data on T/TA needs (listening sessions); and conducting T/TA specific to using telehealth technologies to deliver SUD and MH services. Ongoing monitoring and evaluation will be needed to assess the extent to which virtual T/TA delivery is associated with comparable provider satisfaction, knowledge, skill, and practice implementation, relative to in-person T/TA. Conclusion: The rapid virtualization (Shore 2020) of T/TA services by the TTCs demonstrates adaptability and carries important implications for designing a hybrid service delivery model post pandemic. Background: Pharmacies are well positioned to mitigate opioid risks through provision of naloxone to people taking opioid medications and supplying nonprescription syringes for safe injection. Many pharmacists are unsure of how to address these topics with patients and some may harbor stigma towards people who use drugs (PWUD). We used a participatory design process with multiple stakeholders to integrate two evidence-based opioid safety-focused training toolkits (MOON and RESPOND) to enhance content related to buprenorphine dispensing and nonprescription syringe sales. Methods: MOON materials focused on naloxone knowledge and dispensing; RESPOND emphasized communication strategies and importance of opioid safety screenings. We formed external advisory committees (EACs) across each state comprised of pharmacists, policy makers, community health workers, and researchers (n = 20) to provide feedback via online survey and presentations to local task forces. Three in-person focus groups with PWUD (n = 17) in one urban and two rural areas were held. Toolkits included a continuing education online course, academic detailing, as well as pharmacist-and patientfacing materials. Results: EAC survey responses and task force discussions affirmed the need to focus the online course and academic detailing on naloxone assessment, counseling, and pharmacy workflow. New content and tool enhancement areas pertained to buprenorphine effectiveness, concomitant medication monitoring, prescriber communication; and reducing syringe purchase and sale stigma, community benefit of syringe sales, and importance of safe disposal. Focus group participants discussed toolkit refinements to: (1) reduce stigma, (2) present clear patient-facing messaging with pictures, (3) offer syringe disposal containers, and (4) use training videos with more realistic scenarios. Conclusions: Adaptation and enhancement of a comprehensive, evidence-based toolkit for pharmacists was formalized through a participatory process with multiple stakeholders. Community engagement in intervention development improved the validity and meaning of materials for stakeholders, especially for PWUD. Background: The Implementation & Sustainment Facilitation (ISF) strategy was found to be an effective implementation strategy for improving the integration of a motivational interviewing-based brief intervention for substance use disorders within HIV community-based organizations (CBOs). Using the Grasha-Riechmann framework, which codifies teaching styles into five categories: Delegator, Expert, Facilitator, Formal Authority and Personal Model, we sought to understand the styles used to deliver the ISF strategy. To our knowledge, the Grasha-Riechmann framework has not been applied to a facilitationbased implementation strategy. Methods: The ISF strategy facilitation meetings (n = 137) were recorded and transcribed. Participants included intervention and leadership staff. A deductive, thematic coding framework using the Grasha-Riechmann framework was applied to the transcripts. NVivo qualitative software facilitated coding of text for analysis. Results: Preliminary results show that the Grasha-Riechmann framework is useful for identifying styles of facilitation, as well as the individual elements within those styles. Examples included: Promoting a mechanism or tool that will enable immediate independent work (Delegator); heading off/foreseeing future problems (Expert); offering empathy and/or encouragement (Facilitator); setting expectations (Formal Authority); and providing explicit examples of how the facilitator or others have carried out a task in the past (Personal Model). Conclusion: Results demonstrated the feasibility of using the Grasha-Riechmann framework for coding a facilitation-based implementation strategy. Findings fill a gap in the literature, as few studies to date have examined the techniques employed by facilitators to improve motivational interviewing implementation in HIV-CBOs. A future investigation will employ a mixed-methods approach to compare the qualitative analyses of facilitation transcripts to the fidelity of the ISF strategy and HIV-CBO impact. Triangulating quantitative and qualitative data could provide an opportunity to better understand facilitation-based interventions by using a qualitative approach to validate the quantitative self-report method. Background: The role pharmacies play in addressing the opioid crisis and drug-related risks like injection drug use is evolving. Estimating the prevalence of injection drug use at the community level is challenging due to the hidden nature of drug use. Many community pharmacies sell nonprescription syringes, thus pharmacy-level sales of injection equipment may be an indicator of drug-related harm and unmet need from high-risk populations. We aimed to assess the convergent validity of staff-reported syringe sales volumes and syringe sales data from community pharmacies in Massachusetts and Rhode Island. Methods: Between November 2017 and January 2018, we administered a telephone-based survey to estimate average weekly Addict Sci Clin Pract 2020, 15(Suppl 2):35 nonprescription syringe sale type and volume for 191 retail chain (CVS) pharmacies located in communities experiencing fatal opioid overdoses above the state's annual median rate. For the same period, we obtained syringe sales data from surveyed pharmacies and all CVS pharmacies in the two states. CVS Pharmacy is the largest retail pharmacy chain in both study states. We ran Spearman correlations to assess convergence of average weekly volume between pharmacy staff reports and sales data. Results: All pharmacies responded to the survey. Most (98.4%) pharmacies surveyed sold nonprescription syringes but 41.4% reported running out of stock monthly or more frequently. Pharmacy staff tended to under-report syringe sales. Staff reported weekly nonprescription syringe sales volume was 67,922 compared with 70,962 from the administrative pharmacy sales data. Spearman's correlation between reported and actual syringe sales data was 0.40 (95% CI = 0.27-0.51). Conclusions: Pharmacy syringe sales data can provide a real-time, geographically specific, anonymous data source to track emerging trends and tailor local responses. The counts of administrative pharmacy syringe sales data in Massachusetts and Rhode Island indicate high need, substantial volume, and notable access at community pharmacies. Background: Innovative approaches are needed to address the opioid overdose crisis. Connecting the DOTS-Drug Overdose Trust and Safety, a large-scale SAMHSA-funded project, aims to foster collaboration between historically siloed organizations and community stakeholders, provide occupational safety and harm reduction training to first responders, distribute naloxone, and increase the integration of care coordination services within first responder agencies. Planning sessions were conducted in two counties in Missouri to encourage community collaboration and customize training content. The differences in baseline levels of collaboration and partnership factors between two urban counties were assessed. Methods: Participants were surveyed at the beginning of the planning sessions on their demographic characteristics, current levels of collaboration, anticipated benefits from collaborating, partnership factors, as well as open-ended responses to gauge reasons for attending, expectations, and measures of success. Results: Planning sessions were attended by county health officials, law enforcement, fire and EMS representatives, substance use service providers, and members of local recovery organizations. St. Louis City (STL) attendees were more racially diverse (66.7% White, 26.7% Black) compared to Jackson County (JC) [Kansas City Metro Area] 96.7% White, 3.3% Native American). Attendees reported similar levels of collaboration among participating organizations in each county; however, levels of trust between partners were significantly higher in Jackson County than St. Louis City (F(1,55) = 2.57, p = 0.008). Conclusion: Historical and existing collaboration and partnership differences between STL and JC may be a result of contextual and resource-based differences between the counties. Providing a forum to communicate ideas and issues can mitigate uncertainty and skepticism, eventually building relationships, developing trust, and contributing to the partnerships' success. The baseline scores and differences will inform our approach in adapting the training curriculum to context, fostering impactful partnerships towards reducing opioid overdose mortality rates. Background: The Substance Use Recovery Evaluator (SURE) is a Patient-Reported Outcome Measure developed with extensive involvement from service users. Our study undertakes a psychometric evaluation of the SURE and examines whether it is sensitive in detecting changes in recovery over time. Methods: A total of 222 participants completed the SURE along psychological distress (Kessler-10), substance use (Timeline Follow-Back) and quality of life (Eurohis-8) measures at baseline during residential treatment, and 3-and 6-months after discharge. Confirmatory factor analyses (CFA), internal consistency, and correlations assessed psychometric validity. To assess change over the follow-up period, statistical as well as clinically significant and reliable change indices were calculated. Correlations between mean changes on SURE, Kessler-10 and Eurohis-8 assessed change sensitivity. Results: The CFA suggested a four-factor structure of all SURE items (χ 2 = 22.25, RMR = 0.023, GFI = 0.981, NFI = 0.972) except those from the Material Resources subscale which had low internal consistency and low factor loadings. The total SURE scale and remaining 4 subscales had acceptable to excellent internal consistency (α = 0.7-0.9) and significant correlations with quality of life (r s = 0.73), days of substance use (r s = − 0.51), and psychological distress (r s = 74). There was statistically significant change on the total SURE score, and Drug Use, Self-care and Relationships subscales with medium effect sizes. For the total SURE score, 31% of participants demonstrated reliable deterioration or improvement. SURE mean changes were significantly correlated with mean changes on quality of life (r s = 61) and psychological distress (r s = 50). Discussion: The SURE is a valid and reliable measure which shows change sensitivity, indicates reliable changes over time, and correlates well with other validated measures of treatment outcome. Although the Material Resources subscale might have clinical utility, these items are not recommended for assessing change over time or for research purposes. Background: This work advances efforts to disseminate family-based treatment in routine care for adolescent conduct and substance use problems by examining the construct and predictive validity of core elements of family therapy: Interactional Change, Relational Reframe, Adolescent Engagement, and Relational Emphasis. The core elements were derived from an observational distillation study of high-fidelity family therapy sessions conducted by expert clinicians. Methods: The study sampled recorded sessions and clinical outcome data from 161 cases participating in one of three studies: an implementation trial of Functional Family Therapy (98 sessions/50 cases), an adaptation trial of Multisystemic Therapy (115 sessions/59 cases), and a naturalistic trial of non-manualized family therapy in usual care (107 sessions/52 cases). Adolescents were 60% male with an average Addict Sci Clin Pract 2020, 15(Suppl 2):35 age of 15.4 years (SD = 1.7); 15% were African American, 27% White Non-Hispanic, 49% Hispanic American, and 9% other. Session recordings (n = 320) were randomly selected for each case and coded for 21 discrete techniques. Outcome data were collected through 12-month follow-up. Results: Confirmatory factor analyses replicated the factor structure of the family therapy techniques from the original distillation study, confirming four coherent treatment modules: Interactional Change (ICC = 0.77, Cronbach's α = 0.81); Relational Reframe (ICC = 0.75, α = 0.81); Adolescent Engagement (ICC = 0.72, α = 0.78); Relational Emphasis (ICC = 0.76, α = 0.80). Latent growth curve modeling demonstrated that for each module, greater use of core family techniques predicted improvement in at least one clinical outcome (substance use, externalizing and internalizing problems, family cohesion and conflict); predictive effects were found for multiple outcomes reported by multiple sources. Conclusion: Core elements of empirically supported family therapy models for adolescent behavior problems are clinically viable when delivered in routine care and demonstrate direct links between extensiveness of core module delivery and long-term client gains. Background: Recent state legislation has sought to expand naloxone pharmacy distribution in order to reduce opioid-related harms. This study aimed to examine experts' views on various state-level naloxone pharmacy access policies. Methods: We recruited a purposive sample of 46 key stakeholders (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with experience and expertise in naloxone pharmacy access policies to participate in an online Delphi process. We provided participants with a list of 15 state-level policies: five targeting naloxone prescribers/prescription, six targeting naloxone dispensers/distribution, and four targeting patients/individuals obtaining naloxone. In Round One, stakeholders in Panel A (n = 24) rated the average effect of each policy (assuming it had been implemented as intended) on naloxone pharmacy distribution, opioid use disorder prevalence (OUD), nonfatal opioid overdoses, and opioid overdose mortality. Stakeholders in Panel B (n = 22) rated the acceptability, feasibility, affordability, and equitability of each policy. In Round Two, participants reviewed the Round One results and engaged in an anonymous, moderated, online discussion with other participants. In Round Three, participants revised their Round One responses in light of Round Two. We examined consensus on the effects of opioid-related outcomes (Panel A) and on implementation-related considerations (Panel B). Results: Experts rated three policies to yield a decrease on fatal overdose: Statewide Standing/Protocol Order, Over-the-Counter Pharmacy Supply, and Statewide "Free Naloxone". Of these, experts rated only Statewide Standing/Protocol Order as high on all implementation criteria (i.e., high acceptability, feasibility, affordability, and equitability). Experts perceived liability protections and required provision of education or training as having little-to-no effect on naloxone distribution. All policies had little-to-no change on prevalence of OUD and nonfatal overdose. All Naloxone Dispenser/Distribution policies had high acceptability, while all Naloxone Prescriber/Prescription policies had little-to-no change on fatal overdose. While only five policies (33%) have "high" equitability, no policy has "low" acceptability, feasibility, affordability, or equitability.

Conclusion:
The results of this study will help researchers better characterize naloxone policies and guide policymakers in making decisions about naloxone access. Analyses will inform an evidence-todecision framework for policymakers in this area and will be used in future empirical work characterizing state-level opioid ecosystems. Through an individualized intake session, the TA requester indicates if the TA request involves a unique or hard-to-reach population, such as justiceinvolved populations, people experiencing housing instability, people who are uninsured or underinsured, and Black, Indigenous, people of color (BIPoC) communities.

Methods:
The ORN project team is conducting qualitative analysis to describe the TA type, levels (Basic TA, Targeted TA, and Intensive TA) and types of TA activities. Data analysis includes using consensus methods to synthesize the unique and hard-to-reach TA requests and nominal group technique. Senior researchers lead the group in identifying key terms for coding, iterative coding, and review through consensus sessions. Results: The ORN TA project identified 21 unique and hard-to-reach populations as part of the TA request process (44% of all TA requests).
Twenty key terms were identified. Subsequent rounds of coding and code reviews are taking place, which includes reviews of coded data, thematic analysis, and quantitative descriptive analysis of project data.

Conclusion:
Preliminary results indicate early identification as part of a systematic process to identify unique and hard-to-reach populations may facilitate tailored TA. Individualized support can be given to the TA requester to identify unique and hard-to-reach populations. Further analysis is necessary to identify impact and outcomes on TA delivery across diverse populations. Background: Family therapy (FT) has the strongest evidence base for treating conduct and substance use disorders in adolescents. A fundamental and unique feature of FT models for adolescent externalizing problems that differentiates FT from other approaches is family engagement. Family engagement is characterized by interventions aimed to enhance family members' involvement in therapy and promote investment in the therapy process. The current study leveraged three existing manualized FT models to identify and distill core parent engagement (PE) techniques that are conceptually and clinically distinct from other FT interventions. Then, using a front-line sample to maximize generalizability, this study tested the construct and predictive validity of a PE factor, derived from FT theory and clinical practice. Methods: Sessions were sampled from tapes collected from community clinicians treating adolescents with substance use and co-occurring behavioral problems in usual care. Sessions were observationally coded for the presence of 4 PE techniques: Enhances Love and Commitment, Instills Hope, Parent Ecosystem, and Joins with Parents. Addict Sci Clin Pract 2020, 15(Suppl 2):35 Results: Descriptive statistics for the PE factor demonstrate strong internal consistency (4 techniques; α = 0.71) suggesting a reliable and valid construct. Modest correlation with other FT Factors (i.e., Interactional Change, Relational Reframe, Adolescent Engagement, Relational Emphasis; Hogue et al. 2020) suggests differentiation from other core FT techniques. Latent growth curve modeling was used to examine technique-outcome associations over 12-month followup. PE score was included as a predictor, controlling for FT model, therapist effects, adolescent ethnicity, sex, and age. Results suggest more extensive use of PE techniques was associated with significant decrease in adolescent substance use. Counter to study hypotheses, use of PE techniques was associated with significant increases in internalizing and externalizing symptoms. Conclusion: Frontline therapists employing family-based interventions intensified their use of PE techniques for those youth who behavioral symptoms showed greatest decline over time. Background: In the era of heightened opioid prescribing scrutiny, little research assesses opioid se in cancer patients. We examined patterns of and factors associated with opioid utilization in newly diagnosed cancer patients. Methods: A retrospective cohort study of individuals aged 18 to 64 years with a new cancer diagnosis in IQVIA PharMetrics ® Plus (1/1/2007-12/31/2013). Study participants were continuously enrolled 12 months pre-and 24 months post-cancer diagnosis. Opioid prevalence, total days supplied, number of prescriptions, and Morphine Equivalent Daily Dose (MEDD) were measured in the 2-years following cancer diagnosis. Multivariable logistic regression models identified factors associated with odds of receiving opioids post-cancer diagnosis. Results: Of 191,616 eligible individuals, 93,739 (48.9%) received an opioid after cancer diagnosis; of these, 56,025 (59.8%) were new users. In the 2-years following cancer diagnosis, opioid users received a mean 4.6 prescriptions covering 65 total days supply with a mean MEDD of 31.8 mg. Only 2387 (2.5%) patients had high MEDD (≥ 90 mg). Baseline predictors of opioid use after cancer diagnosis included secondary cancer [OR 2.47

Conclusions:
We found no evidence of excessive opioid use following new cancer diagnoses. Cancer-related factors, including site and progression to secondary cancer, were among the strongest predictors of opioid use in the cancer population. Current policies to reduce opioid overuse and adverse events may unintentionally impact access to opioid medications used to treat cancer-related pain. In order to avoid under-treatment of cancer pain, patient-centered policies and prescribing practices should be adopted to minimize unintended consequences of broad opioid policies intended to limit inappropriate opioid use. Background: Buprenorphine/naloxone (BNX) and naltrexone (NTX) are critical components of addressing the current opioid epidemic, yet treatment need vastly exceeds treatment availability. In Rhode Island, one new model of MAT provision considered the expansion of BNX and NTX care into pharmacies through a collaborative pharmacy practice agreement (CPA). The current study aimed to determine the feasibility of providing pharmacy-based MAT care to 11 patients with opioid use disorder, and to consider adaptations of this model during COVID-19. Methods: A CPA for MAT was developed by state, community pharmacy, and study team members, drawing from existing MAT models of nurse case manager office-based care and adapting extant pharmacy-MAT models for community pharmacies. Once approved by state officials, we trained 17 pharmacists in MAT care provision principles over a 20-h online and in-person course designed in partnership with national organizations for the study. We then piloted the CPA with 11 patients receiving BNX maintenance doses who visited the study pharmacy at least weekly for 1 month. All toxicological testing was oral and observed; pharmacy care notes were provided to the collaborating prescriber within 8 h of visits. Study assessments were in-person and included self-reported behavioral measures of drug use, safety, and social and health stability and clinical measures such as drug toxicology, counseling, and clinic visit attendance. Feasibility was assessed from patients as well as from pharmacists delivering the intervention through a self-reported Likert-scale item. During the COVID-19 crisis, state and community concerns for broader MAT care brought about further CPA adaptations. Results: Eleven patients (5 women, 6 men, 40% non-white race) aged 23 to 60 years completed 70 clinic visits for buprenorphine care at two locations. There were no adverse events and patients with mandated counseling and other requirements continued in their receipt. Pilot participants were safely transitioned to and from the pharmacy. All pharmacists rated the CPA model highly feasible; patients similarly rated the care receipt highly. Patients noted the efficient care, flexibility, family-friendly setting, and low perceived stigma of the pharmacy experience. During COVID-19, changes in permissions from DEA/ SAMHSA led to expanding the CPA to support withdrawal care management and pharmacy-facilitated induction. Conclusion: Findings suggest that a CPA care model is feasible and safe for patients on MAT and pharmacists. The CPA model for MAT can further engage pharmacists as part of the patient care team to meet the dynamic needs of patients including during the COVID-19 crisis. Little is known about rural provider perceptions/attitudes when treating pregnant patients with opioid use disorder (OUD). Objective: To evaluate health care provider perceptions/attitudes on providing care to patients with prenatal OUD (POUD). Methods: Design. This study was a cross-sectional, one-time closeended/self-report electronic survey. Setting. The survey was distributed within two high opioid prescribing/overdose counties in rural Utah. All health/behavioral health care providers listed in Utah's professional license database in the targeted counties were contacted. Assessments. We adapted the Shortened Alcohol and Alcohol Problems Perception Questionnaire to assess provider perceptions/attitudes towards POUD. Analyses. We employed descriptive statistics to Addict Sci Clin Pract 2020, 15(Suppl 2):35 characterize the sample; ANOVA and unadjusted/multivariable linear regression tests analyzed provider perceptions/attitudes by key indicators. Results: A total of 225 providers consented to participate in the survey (response rate = 52%). Following screening, 82 providers indicated they provide care for pregnant women with opioid use disorder. Participants included nurses/nurse practitioners/nurse midwifes (54.7%), counselors/therapists/social workers (34.0%), physicians (5.7%), and physician assistants (5.7%). The provider perception/attitude score ranged from 10 to 70 (10 = negative; 70 = positive). A significant difference in mean scores was found between professions (overall mean = 52.1, SD = 9.8, p = 0.04) with nurses having the lowest score (mean = 47.8, SD = 7.1) and nurse practitioners with the highest score (mean = 59.9, SD = 8.4). Adjusted linear regression analyses (adjusted for demographics) showed more hours of prenatal opioid education training were associated with lower perception/attitude scores (β = 2.63, 95% CI [0.72, 4.54], p < 0.01) and providers who feel more competent in asking pregnant patients about opioid use were associated with lower perception/attitude scores (β = 4.81, 95% CI [2.00, 7.62], p < 0.01). Conclusions: Additional education may benefit rural provider's perceptions/attitudes in providing POUD care. Future research should design/test interventions to improve rural POUD care. Background: Under-treatment of drug and alcohol use in primary care settings has been attributed, in part, to medical providers' negative attitudes toward substance use. As a part of an implementation study of EHR-integrated substance use screening in primary care clinics, conducted in the NIDA Clinical Trials Network, we assessed baseline attitudes among medical staff. Methods: Eligible participants were primary care providers and medical assistants in six urban academic primary care clinics. Prior to implementation of a substance use screening program, participants completed the Substance Abuse Attitudes Survey (SAAS), a validated 50-item self-administered survey that measures attitudes to substance use in five domains: permissiveness, non-moralism, non-stereotyping, treatment intervention, and treatment optimism. Participants were asked to rate their level of agreement with each item on a five-point Likert scale. Results: In total, 139/191 (73% response rate) eligible staff completed the survey. Participants were age m = 42; 75% female; 10% Hispanic/ Latino, 65% White, 6% Black, 25% Asian (multi-race selection allowed). The sample comprised 78% physicians, 9% nurse practitioners, and 11% medical assistants with an overall average of 13.4 years in practice. Approximately one-third reported moderate to high satisfaction treating patients with drug problems (37.3%) and alcohol problems (36.7%). The proportion of participants having positive attitudes in each of the following domains were: non-moralism (70.1%); non-stereotyping (58.3%); treatment intervention (48.6%); treatment optimism (49.6%); and permissiveness (46.2%). Conclusions: While most primary care staff did not endorse moralistic or stereotyping statements about alcohol and drug use, attitudes toward addiction treatment were mixed, with less than half endorsing positive attitudes toward treatment effectiveness. Our results suggest a need to improve attitudes, particularly toward addiction treatment. This could be accomplished through education and increased exposure to effective interventions that can be delivered by primary care providers, including office-based treatment for alcohol and opioid use disorder. Background: UNAIDS recommends integration of medications for substance use disorders (SUD) with HIV care to improve HIV outcomes. Yet, integration of HIV and SUD services remains limited in many countries. The objective of this study was to assess provider perceptions of care integration in Vietnam. Methods: Qualitative interviews were conducted with 43 healthcare providers (nurses, physicians, counsellors, pharmacists, and clinic managers) in 8 HIV clinics in northern Vietnam, 2013-2015. Interviews, each of which lasted between 30 and 60 min, were digitally audiorecorded with the consent of the participants. Thematic analysis with a mixed deductive and inductive approach at the semantic level was employed to analyze key topics. Results: Five themes were identified from providers' attitudes regarding integration of HIV and SUD treatment: (1) integration of treatment for alcohol use disorder is often neglected compared to other SUD treatment; (2) structural challenges must be addressed to increase integration feasibility; (3) integrated care must address workforce limitations; (4) integration must overcome societal and healthcare stigmatization of SUD; and, (5) providers must resolve conflicting views to overcome integration challenges. Conclusion: The experience of providers in Vietnam may be useful to other countries attempting to integrate HIV and SUD services. This study provides critical insights from the perspective of healthcare providers for integrating HIV and SUD treatment in Vietnam, which could inform scale-up of integrated HIV and SUD services in other countries. Background: Behavioral health diagnoses are frequently underreported in administrative health data. As part of a pragmatic trial of a hospital addiction consult program, we sought to determine the sensitivity of New York State Medicaid paid claims data for identifying hospital inpatient admissions with opioid use disorder (OUD) in six New York City public hospitals. Methods: We conducted a structured chart review of electronic health records to identify patients with OUD at the time of their hospitalization. Cases selected for review were 2017 admissions to medical/surgical inpatient units of adults who received methadone or buprenorphine in the hospital. The target sample was 100 cases per hospital. Clinicians with addiction medicine expertise reviewed medical charts to determine if the patient had a clinical presentation consistent with OUD during the hospitalization. For those with OUD, we searched for the same hospitalization in NY State Medicaid paid claims data using demographics, hospital identifiers, and admission dates, and examined all ICD-10 discharge diagnoses associated with the admission for codes including OUD/opioid poisoning. Sensitivity was calculated based on cases that were found in the claims data; because our concern was for underreporting of OUD, specificity was not explored. Addict Sci Clin Pract 2020, 15(Suppl 2):35 Results: A total of 591 cases were reviewed; 552 (93%) were clinically consistent with OUD. 465 (84%) of the OUD cases were found in the paid claims data, of which 418 (90%) had a discharge diagnosis of OUD or opioid poisoning. There was variation between hospitals, with the rate of capture ranging from 83 to 97%. Conclusion: For hospitalized patients receiving OUD medications, paid public insurance claims appear to have good sensitivity for capturing opioid-related diagnoses. Claims data may be a valuable source of information about treatment and outcomes of this population. Background: Recent research shows that individuals with networks comprised of greater proportions of drinking partners are more likely to experience risk factors for DUI; furthermore, reductions in network proportions of drinking partners following a DUI is associated with improved drinking outcomes. The present study builds on this prior work by exploring changes in individual's network members following a DUI through a multilevel lens. Methods: We collected ego-centric social network data on network members in the 2 weeks prior to DUI incident and at completion of the DUI treatment program for a sample of participants (n = 94) enrolled in a larger randomized controlled trial comparing the effects of cognitive behavioral therapy with usual care. We employed multilevel modeling to examine the associations between participant and network member characteristics and network member retention, drinking, and support at followup. Results: Our results indicate that participants were significantly more likely to retain network members with whom they drank and received tangible support from and significantly less likely to retain network members with whom they drank more alcohol than they wanted. Participants were more likely to receive support for reducing drinking from those with whom they drank, those who provided emotional support, and those who provided DUI-specific support. Conclusion: Although prior research shows that having a greater proportion of drinking partners in ones network is associated with risk for DUI, drinking partners are significantly more likely to be retained in networks following a DUI incident. Despite these potential risks, individuals with a first-time DUI were more likely to receive support for reduced drinking from those with whom they drink. The results of this work highlight the importance of multiplexity-an overlap in functions of network members-in research on the social context of drinking. Background: Currently, there is no consensus on how to measure cannabis retailer density. Researchers and policy makers need clear measures to support policies that mitigate unintended harms of cannabis legalization. To address this gap, we developed cannabis retailer density metrics and assessed whether they were associated with young adult cannabis use in Los Angeles County (LA), California. Methods: Drawing from GIS-based measures of alcohol outlet density, we developed a series of cannabis retailer density metrics: proximity, counts within 5-10-15-, and 30-min driving distances, and considered retail licensure. Retailer addresses were compiled by webscraping cannabis registries (e.g., Weedmaps) and conducting field visits (March 2019). Home addresses were geocoded for young adults who completed a 2019 survey (no. 1097); retailer metrics were calculated for each participant. We fit a series of multilevel logistic regression models to assess which retailer metrics were associated with any past month cannabis use. Models included a random intercept by census tract (CT) and adjusted for age, gender, race/ethnicity, college student, and CT median household income. Results: Thirty percent of young adults used cannabis in the past month, 39% had a retailer within a mile from home, and an average of 14 retailers within a 10-min drive. Licensed retailers were less prevalent; nearest licensed retailer was on average 2.4 miles from home. The odds of past month cannabis use significantly increased by 3% (OR: 1.03, 95% CI 1.00-1.07) for every additional licensed retailer within a 10-min drive in adjusted model; use was also significantly associated with licensed retailers within a 30-min drive (OR: 1.01, 95% CI 1.00-1.01). Other metrics were not significantly associated with past month cannabis use. Conclusion: Findings indicate density metrics may be important indicators for risk among young adults. Such findings can be used to inform policy, prevention, and intervention efforts.

A85
"The influence of an opioid use disorder on initiating physical therapy for low back pain: a retrospective cohort" (MM18) Jake Magel, Adam Gordon, Julie Fritz, and Jaewhan Kim Lead Author Affiliation: University of Utah, 201 Presidents' Cir, Salt Lake City, UT 84112, USA Correspondence: Jake Magel (jake.magel@hsc.utah.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A85 Background: Low back pain (LBP) is common among patients with an opioid use disorder (OUD). Primary care providers (PCPs) are often the first health care providers consulted when patients seek care for LBP. After this initial encounter, patients are frequently managed in physical therapy. The extent to which patients with an OUD initiate physical therapy for LBP is unknown. To examine the association between a history of an OUD and initiation of physical therapy for LBP within 60 days of a PCP visit for this condition. Methods: Claims from a single state-wide all payer claims database from June 30, 2013 and August 31, 2015 were used to establish a retrospective cohort of patients who consulted a PCP for a new episode of LBP. The outcome measure was the presence of at least 1 physical therapy claim within 60-days after the PCP visit. After propensity score matching on covariates (age, sex, prior history of LBP, comorbid neck pain, obesity, chronic pain, mental health comorbidity, pain medications, residence, insurance carrier and high deductible health plan), logistic regression was used to compare the outcome between patients with a history of an OUD to patients without an OUD. Results: Propensity score matching resulted in 1360 matched pairs of participants with a mean age of 47.2 years (15.9) and 55.9% were female. Compared to patients without an OUD, patients with an OUD were less likely to initiate physical therapy for LBP (aOR = 0.65, 95% CI 0.49 to 0.85). Conclusions: After a visit to a PCP for a new episode of care for LBP, patients with a history of an OUD are less likely to initiate physical therapy than those without an OUD. PCPs may find the results of this study useful when considering the referral of patients with LBP for rehabilitation who have a comorbid OUD.
Background: Given the major societal disruptions of the COVID-19 pandemic and its accompanying stressors, concerns are growing that the pandemic is increasing substance use, particularly among individuals with chronic conditions, such as HIV. This study aimed to understand the perceived impacts of COVID-19 on substance use among clients served by HIV service organizations (HSOs) and whether those impacts also increase the need for substance use disorder (SUD) treatment integration in these organizations. Methods: In April 2020, key staff members from 253 HSOs across the US completed an online survey focused on the HSO's capacity to provide substance use treatment services to clients with SUDs. Survey items measured perceptions of the impact of the COVID-19 pandemic on: (a) their clients' substance use and (b) increasing the need for the HSO to offer substance use treatment services to clients with SUD, using a scale from 0 representing 'Not at all' to 3 representing 'To a great extent.' Results: Overall, 57% (n = 143) of HSOs reported providing substance use services as part of their service offerings. The average perceived impacts of COVID-19 on clients' substance use was 2.3 (SD = 0.7), was 2.2 (SD = 0.7) for increasing the prevalence of SUDs among the HSO's clients, and was 2.1 (SD = 0.8) for increasing the need for the HSO offer effective substance use treatment interventions. HSOs currently lacking substance use services reported lower perceived need to offer effective treatment interventions because of COVID-19 (mean = 2.0, SD = 0.9) than HSOs that currently offer substance use services (mean = 2.3, SD = 0.7, p = 0.002). Conclusions: From the perspective of HSOs, COVID-19 is likely to increase substance use and the prevalence of SUDs among clients served by their organizations. Increases in the prevalence of SUDs due to COVID-19 raise the urgency of integrating SUD interventions into HSOs across the US. Background: People living with HIV (PLWH) and substance use disorder (SUD) frequently use acute care services but how use of multiple substances relates to utilization has not been well-described.
To determine whether patterns of substance use are associated with acute healthcare utilization among PLWH with SUD. Methods: Participants were recruited from two urban HIV primary care clinics. Inclusion criteria were: (1) HIV infection in medical records, (2) Current DSM-IV substance dependence, or ever injection drug use. Acute healthcare utilization was defined as any past 3-month emergency department visit or hospitalization. Based on latent class analysis, the substance use patterns were: (1) mostly cannabis and unhealthy alcohol use; (2) polysubstance (opioids, cannabis, tranquilizers, cocaine, and unhealthy alcohol use); (3) no drug or unhealthy alcohol use. Past 30-day drug use was assessed using the Addiction Severity Index. Unhealthy alcohol use was assessed with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Analysis: generalized estimating equations from repeated measures at baseline, 12-, and 24-month follow-up, adjusting for sociodemographic variables. Results: Among 250 participants, mean ± SD age was 49 ± 9 years, 63% were male, 30% Hispanic, 71% had HIV viral load < 200 copies/ mL; 157 (62.8%) were categorized as cannabis and unhealthy alcohol use; 49 (19.6%) as polysubstance use; and 44 (17.6%) as no drug or unhealthy alcohol use; 46% reported acute healthcare utilization. Although there was a trend (acute healthcare utilization 34%, 47%, 53%, respectively; unadjusted p = 0.07), after adjustment there were no significant associations, compared to no substance use, between (1) cannabis and unhealthy alcohol use [adjusted odds ratio (aOR) = 1.17 (95% confidence interval (CI) 0.75, 1.82)], or (2) polysubstance use [aOR = 1.40 (95% CI 0.81, 2.40)], and acute healthcare utilization. Conclusion: Among PLWH with SUD, we did not detect an association between substance use patterns and acute healthcare utilization. Future studies should assess longitudinal effects in larger samples.
Background: Many states have implemented opioid days' supply restriction policies, leading to reductions in opioid prescribing. Although research within certain provider types exist, no study has evaluated an opioid restriction policy by various provider types. To evaluate changes in mean days' supply (MDS) and morphine milligram equivalents (MMEs) dispensed per opioid prescription before and after Florida's restriction policy (implemented on 7/1/2018), stratified by provider type: surgery, emergency medicine, primary care, and dentistry. Methods: We used prescription claims of a private health plan serving a large Florida employer from 1/1/2015 to 3/31/2019. Interrupted time series analyses were conducted to compare pre and post-implementation changes in MDS and MMEs for opioid medications stratified by Healthcare Provider Taxonomy Code using providers' national provider identifier (NPI). Results: Among 8000 opioid initiators, treating providers were classified as surgery 21.7% (n = 1732), emergency medicine 19.0% (n = 1516), primary care 28.0% (n = 2241), and dentistry 31.4% (n = 2511). For surgery, the MDS was 5.4 which resulted in a nonsignificant decrease to 3.9 following implementation (p = 0.055) and mean MME of 212 with a non-significant reduction after implementation (p = 0.244). In emergency medicine, MDS was 3.5 with a reduction to 2.8 following implementation (p = 0.036) and mean MME was 88 with a reduction to 61 following policy enaction (p = 0.001). For primary care providers, MDS was 8.9 with a reduction to 5.7 following implementation (p = 0.011); however, the mean MME was 185 with no significant reduction after the law enacted (p = 0.219). The MDS was 3.5 for dentistry with a reduction to 3.0 following implementation (p = 0.012); however, the mean MME was 116 with no significant reduction after implementation (p = 0.557). Additionally, changes in trends of opioid prescribing varied over time following implementation by provider type. Conclusion: Pre-policy opioid prescribing varied by provider type with a differential impact on MDS and MMEs dispensed per prescription following implementation. Background: In response to the epidemic of opioid-related overdoses and deaths in the United States, several states have passed legislation limiting the prescribing of opioids for acute pain. Previous studies address state-specific legislation restrictions; however, many studies failed to examine the details of these restrictions across each of the 50 states. We aimed to summarize the state-specific limitations on the day's supply or total morphine milligram equivalents (MMEs) per day of the prescription, any individual opioid prescriber stipulation in the laws, and any exemptions to these policies. Methods: We utilized publicly available legislative online libraries to search for statutes and State Code amendments pertaining to opioid restrictions through May 1, 2020. Elements collected from each state included: the specific legislative policy on prescribing of adult and pediatric patients, the practitioner to whom the law applied, exemptions to the legislation, and the timeline of policy enactment. Results: In the United States, as of May 2020, 37 states have enacted an opioid prescribing restriction. Thirty of the 37 states (81%) have limits only on the number of days' supply allowed, and 7 (19%) have limits on the MMEs and days' supply for acute pain conditions. A total of 13 states (35%) have distinctions on what type of prescriber the restriction applied to and a total of 8 states (22%) have different limitations for pediatric patients. All states with opioid limitations have chronic pain restriction exemptions, but these vary across each individual state. Conclusion: This study shows an uptake in increased state restrictions for prescribing of opioids for acute pain across the United States. Due to a lack of federal policy, there is no uniformity amongst these prescribing restrictions. Future studies evaluating national trends and opioid policy evaluations must account for the different implementation timelines of prescribing restriction laws. Addict Sci Clin Pract 2020, 15(Suppl 2):35 plans, however little is known regarding how MCO plans manage access to opioid use disorder medications. Methods: We conducted a content analysis of all Medicaid MCO plans across 39 states in 2018 (n = 264) using publicly-available documentation (member handbooks, provider manuals, drug formularies) on coverage and utilization management policies for all medications FDA approved for opioid use disorder treatment. Descriptive statistics were used to compare coverage and utilization management policies for injectable naltrexone, buprenorphine, and methadone. For comparison, we also examined naloxone which is used for the treatment of opioid overdose. Results: A little more than half (55.6%) of all Medicaid MCO plans covered all three opioid use disorder medications. Almost all MCO plans covered buprenorphine (98.1%), while about 72% of plans covered methadone or injectable naltrexone. Coverage of methadone and injectable naltrexone showed the widest variation by state. In 49% of states, all MCO plans covered methadone, while no MCO plans covered methadone in 18% of states. In 36% of states, all MCO plans covered injectable naltrexone and in 18% of states, no MCO plans covered the medication. We also found variation in utilization management policies across medications. Prior authorization was required by 53% of plans for buprenorphine, 52% for methadone and 42% for injectable naltrexone. In contrast, only 10% of plans required prior authorization for naloxone. Utilization management policies also showed variation by state. In 33% of states, all MCO plans required prior authorization for buprenorphine and in 28% of states, no MCO plans required prior authorization for the medication. In 19% of states, all MCO plans required prior authorization for injectable naltrexone and in 47% of states, no MCO plans required prior authorization for the medication. In contrast, 87% of states did not require prior authorization for naloxone in all MCO plans. Conclusion: Our findings suggest that Medicaid enrollees' access to medications may be heavily influenced by the state they live in and the particular MCO plan in which they enroll. State Medicaid agencies may need to restructure MCO contracts to ensure more equitable access to medications for the treatment of opioid use disorder. Background: Explore Region 10 workforce perspectives of key training and technical assistance needs to support workforce efforts to integrate behavioral health services in primary care. Herein, results are described of an online needs assessment survey completed by addiction workforce members in Health and Human Services (HHS) Region 10. Methods: Seven survey items concern practices specific to integrating behavioral health services in primary care, for which importance as a workforce development priority was rated on a five-point Likert scale (1 = Not At All, 5 = Extremely). A lone inclusion criteria for survey respondents, recruited via the Northwest Addiction Technology Transfer Center (Northwest ATTC) website, was current employment as a health professional in an HHS Region 10 state (i.e., AK, ID, OR, WA). Results: Among this addiction workforce sample (N = 306), the three practices most highly-rated as integration workforce development priorities were: (1) multidisciplinary staff teamwork to meet the clinical challenges (M = 4.31, SD = 0.89), (2) orientation to substance use disorders as a form of chronic illness (M = 4.23, SD = 0.89), and (3) referral processes to link persons to longer-term treatment (M = 4.20 SD = 0.89).

Conclusions:
Findings identify targets the Region 10 workforce members see as most important for integrating behavioral health services into primary care. These findings suggest a need to focus on providing training and technical assistance to promote skills related to multidisciplinary staff teamwork, orientation to substance use disorders (SUD) as a form of chronic illness, and referral processes to link persons to longer-term treatment. This will inform future efforts by the Northwest ATTC, and others similarly seeking to address workforce development issues, around integration of addiction services into primary care settings. Background: Availability and use of cannabis is changing rapidly in the United States as legislation expands legal markets for cannabis. Increased access to cannabis retailers and products may increase likelihood of cannabis use disorder (CUD). We examine whether density of cannabis retailers is related to prevalence of CUD for Veterans Health Affairs (VA) patients in King County, Washington. Methods: This ecological, cross-sectional study considered 85 zip codes in King County (includes Seattle) where recreational and medical cannabis is legal. Counts of active cannabis retailers within zip codes were obtained from the Washington State Liquor and Cannabis Board. VA patients living in King County were included if they had ≥ 1 electronic health record-documented visit over 2 years (7/8/2015-7/31/2017). CUD was determined by the presence of ≥ 1 diagnostic code in the year prior to the visit, and counts of patients with CUD were aggregated by zip code. Using Poisson-lognormal spatial random effects models, fit using integrated nested Laplace approximation, we estimated the relative risk of CUD associated with cannabis retailer density, adjusted for population characteristics (age, race, gender) at the zip-code level. Posterior median estimates of relative risk were extracted for all zip codes and mapped to explore spatial structuring. Results: A total of 91 cannabis retailers and 19,246 VA patients contributed data to analyses. A majority of patients were older (median age = 62), male (90%), and white (80%). The average number of observed CUD cases in each zip code was 5.0 (0-37). Spatial variability in CUD risk was observed across zip codes. One additional cannabis retailer was associated with a 7.6% (95% credible interval: 0.9%-14.4%) increase in area-level CUD risk. Conclusion: Areas in King County, Washington with a high density of cannabis retailers also had a higher prevalence of VA patients with CUD. Further research is needed to understand temporality of this association. Results: Participants were (76 male, 77 female, 1 transgender) mean age (55 male; 50.8 female), and 94% had active healthcare insurance. Age of first alcohol consumption was similar between genders, (mean = 15 years old), the mean age for self-identifying problematic alcohol consumption was 30 (28.8 male, 31.2 female). Overall there were significant differences by gender in longest mean duration of abstinence (male 8.48 years; female 5.77 years) (p < 0.01; Cohen's d = 0.440). There was a significant difference between number of disclosure groupings and longest abstinence (ranked ANOVA, p < 0.001; Cohens f = 0.605). Mean longest period of abstinence was increased for those who disclosed to grandparents, parents, children, employers, support group members, and healthcare providers. Those who disclosed to health care providers (n = 95) compared with those who had not (n = 57) had a significant difference in longest mean abstinence (8.39 vs. 4.97 years) (p = 0.011; Cohen's d = 0.416). Among those with medical conditions (n = 73) and those without (n = 80), longest mean abstinence was approximately double (9.66 vs. 4.80 years), (p < 0.001; Cohen's d = 0.621). This was similar to disclosing to close family members. Conclusion: Disclosure to health care providers was associated with significantly longer abstinence, particularly for those with medical conditions. Findings indicate the importance of disclosing recovery status to health care providers, working to reduce the time to seeking treatment, and identifying problematic alcohol consumption earlier.

A94
As those with medical condition had longer sobriety, more integrated care could be beneficial. Background: Opioid use disorder (OUD) and suicide are urgent crises. OUD is associated with increased suicidality (ideation/attempt). It is important that patients with suicidality and OUD receive evidence-based medications to treat OUD (MOUD), which may lower risk of suicide. MOUD include agonists (methadone/buprenorphine) which are first-line treatments that reduce opioid use and overdose risk, and an antagonist (injectable naltrexone) which reduces craving and use. It is unknown whether suicidality impacts likelihood of receiving MOUD. We examined whether documented suicidality was associated with MOUD receipt among Veterans Health Administration (VA) patients with OUD. Methods: Electronic health record data were extracted for all VA outpatients with ≥ 1 preventive screen indicating a visit (10/1/09-7/31/17) with prior-year documentation of OUD diagnosis. In crosssectional analyses using most recent visit, Poisson regression with robust standard errors clustered on facility estimated relative risk (RR) of receiving MOUD (≥ 1 clinic code/filled prescription for methadone, buprenorphine, and/or injectable naltrexone in years prior to/following visit) for patients with suicidality (≥ 1 diagnostic code/ risk flag indicating prior-year ideation/attempt) relative to those without. Models were adjusted for sociodemographics and comorbidities. Secondary analyses examined individual medications. Results: Among 88,207 patients, 12.8% (n = 11,313) had documented suicidality. Suicidality was negatively associated with receipt of any MOUD (RR 0.82, 95% confidence interval [CI] 0.77-0.86). Results were similar for methadone and buprenorphine individually, but suicidality was positively associated with injectable naltrexone receipt (RR 1.40, 95% CI 1.17-1.67).

Conclusion:
Among VA outpatients with OUD, those with documented suicidality may be less likely to receive any MOUD and first-line agonists (methadone/buprenorphine), but more likely to receive injectable naltrexone. Longitudinal analyses are planned to establish temporality between suicidality and subsequent MOUD receipt, as associations might reflect reverse causation (i.e., MOUD may impact likelihood of suicidality). Health system interventions may be needed to ensure patients with OUD and suicidality receive life-saving medications.

A97
"From policy to practice: the real-world impacts of medicaid system transformation on substance use disorder treatment programs" Background: The Affordable Care Act (ACA) and MediCal 1115 Waiver for substance use disorder (SUD) services in California required SUD treatment organizations to integrate themselves into medical systems of care for reimbursement. Our main research question was to learn the anticipated impacts of ACA and the Medi-Cal Waiver on service delivery pre-implementation, and how these changes impacted these organizations and access and engagement in care post-implementation. Methods: A pre-and post-ACA longitudinal qualitative research design was developed to understand policy implementation regarding in SUD treatment organizations. Informed by constructive grounded theory, we rely on Dedoose to analyze an average of 30 semi-structured interview transcripts with clinical supervisors in each of the three waves (2013, 2015, and 2017). These supervisors have played a key role in the implementation of system-wide reforms and integration of care. Results: In 2013, supervisors anticipated increased service utilization but with a strict managed care approach to justify medical necessity leading to a loss of control over treatment decisions. Supervisors also anticipated significant need for workforce training challenging their ability to satisfy increased service demand. Following ACA implementation (2015), supervisors reported an increased emphasis on evidence-based practices, pharmacotherapy, harm-reduction, a clientele with higher SUD severity, and higher rates of co-occurring medical conditions. In 2017, supervisors reported that the county implementation of the 1115 Waiver accelerated these trends making it difficult for providers to adapt to an environment that seemed to be perpetually changing.

Conclusions:
The ACA and 1115 Waiver have changed the client population and services that SUD organizations need to provide. The major changes brought by about these policies in rapid succession proved challenging for treatment providers. Programs may benefit from more gradual implementation of system transformation, or greater support to ramp up organizational and clinical capacity during times of transition. Addict Sci Clin Pract 2020, 15(Suppl 2):35 toward creating a typology of laws regulating OUD treatment access and treatment provision. Methods: Using search terms related to medications for OUD, we conducted searches in Westlaw software for state regulations and statutes in 51 US jurisdictions from 2005 to 2019. We identified OBBT laws and inductively analyzed them for themes using Dedoose software. Results: Since 2005, ten states have passed a total of 181 OBBT laws. We identified the following themes: (1) provider credentials: statelevel licensure for OBBT providers, continuing medical education requirements, supervision requirements for physician-extenders, and state registration requirements; (2) new patients: objective symptoms patients must have prior to receiving OBBT and exceptions for special populations; (3) educating patients: general informed consent requirements, and specific information to provide; (4) counseling: minimum counselor credentials, minimum counseling frequency, counseling alternatives; (5) patient monitoring: required prescription drug monitoring checks, frequency of drug screening, and responses to lost/ stolen medications; (6) effective care: evidence-based treatment protocols, minimum clinician-patient contact frequency, health assessment requirements, and individualized treatment planning); and (7) patient safety: reconciling prescriptions, dosage limitations, naloxone co-prescribing, tapering, and office closures. Conclusions: US state laws vary widely in the extent to which they place requirements beyond federal law on OBBT providers. Some laws codify practices for which scientific consensus is lacking. Additionally, some OBBT laws resemble opioid treatment program and pain management regulations. Results could serve as the basis for a typology of laws impacting OUD treatment and contribute to efforts to empirically examine how state policies affect treatment access and quality. Background: Despite increased focus on opioid use in the general population, studies on opioid use alone and in combination with pain adjuvant medications, in LTC populations are lacking. Methods: We linked 2011 to 2015 annual files from LTCfocus.org data, a 5% random sample of Medicare beneficiary claims (CCW), and the Minimum Data Set 3.0 (MDS) to identify a cohort of non-comatose LTC stays (> 100 custodial days) with continuous Medicare Parts A,B&D coverage. Any opioid use, and opioid use in combination with one or more pain adjuvant medications (NSAIDs, acetaminophen, triptans, anticonvulsants, muscle relaxants (MR), tricyclic antidepressants, and other antidepressants) was identified in the general population and among residents with Alzheimer's and related dementias (ADRD), cancer, non-cancer chronic pain (NCCP), and in hospice. To quantify annual changes, we used a generalized estimating equation (with binomial distribution), adjusting for facility (resident population, occupancy and size, ownership, available special units, hospitalization rate, and staffing) and resident (age, sex, race, original reason for entitlement, follow-up time) factors. Results: We found 84,529 LTC residents with 122,970 linked LTC stayyears. Opioid use was found in 40.5% of all LTC, 41.7% of hospice, 50.1% of cancer, 47.4% of NCCP, and 36.4% of dementia stays. From 2011 to 2015, analyses adjusted for facility and resident characteristics did not indicate constant or significant changes in dose, duration, or frequency of opioid use in general, hospice, cancer, NCCP, or dementia LTC related stays. Odds of opioid + skeletal muscle relaxant use increased by 81%, 26%, 75%, 114%, and 116% in the general, hospice, NCCP, cancer, and dementia LTC stay-years, respectively. Odds of opioid + anticonvulsant use also increased across stay-years, with odds in 2015 31%, 8%, 32%, 39%, and 33% greater than 2011 among general, hospice, NCCP, cancer, and dementia LTC stay-years, respectively. Conclusion: Opioid use in combination with anticonvulsants and MR rose significantly among LTC stays from 2011 to 2015. More study into the safety of these medication combinations in these populations is warranted.

A109
"TxMOUD: using SHIFT-evidence for statewide implementation of medication for opioid use disorder" (SW22) Shaun Jones, Sedona Koenders, Suyen Schneegans, Kristen Rosen, Holly Lanham, Erin Finley, and Jennifer Sharpe Potter Lead Author Affiliation: University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA Correspondence: Shaun Jones (joness8@uthscsa.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A109 Background: Texas Medication for Opioid Use Disorder (TxMOUD) is a state-wide initiative to expand access to evidence-based treatment for opioid use disorder (OUD). TxMOUD has two key components: a training and technical assistance hub and funding for medication and associated treatment services for those without access. To ensure orderly, theory-based implementation across a complex healthcare landscape, we drew upon the Successful Healthcare Improvement for Translating Evidence in complex systems (SHIFT-Evidence) framework to guide implementation and evaluation. Methods: Initial planning was informed by systematic review of barriers to buprenorphine treatment and findings from stakeholder engagement activities in a previous project, GetWaiveredTX. To track use of implementation and evaluation strategies across each SHIFT-Evidence level (patient, provider, microsystem, and macrosystem), our transdisciplinary team developed a conceptual framework to summarize TxMOUD activities. We delineated each activity ordered by level of implementation and identified corresponding implementation strategies. Each activity was cross-referenced with previously identified barriers to ensure all barriers were addressed and foreseeable concerns minimized. Results: The resulting comprehensive SHIFT-Evidence framework informs the ongoing implementation and evaluation of our OUD treatment initiative. A major advantage of this framework is that it allows us to rapidly review our activities and address emergent barriers informed by evaluation data. In the spirit of SHIFT-evidence, we are flexible and pragmatic in upholding this framework, making revisions as necessary when strategies are no longer appropriate or require refinement. Conclusion: We developed this SHIFT-Evidence framework for TxMOUD as a pragmatic and robust decision-making tool to support systematic implementation and evaluation of a large-scale OUD treatment initiative. Integration of novel implementation science frameworks and approaches can support rapid and effective translation of addiction science into practice while accounting for the unique needs and resources of diverse settings and patient populations. Background: To conduct a pilot randomized controlled trial evaluating the treatment effects of a smartphone video directly observed Addict Sci Clin Pract 2020, 15(Suppl 2):35 therapy (DOT) application for patients who recently enrolled in officebased opioid use disorder treatment with buprenorphine. Methods: Adults (≥ 18 years old) prescribed sublingual buprenorphine for < 28 days were recruited from office-based programs at two urban medical centers and randomized to video DOT (intervention)-delivered via a HIPAA-compliant, asynchronous, mobile health technology platform-or treatment-as-usual (TAU) for 12 weeks. Intervention participants were instructed to record daily videos of buprenorphine self-administration. Study outcomes were: (1) percentage of the 12 weekly urine drug tests negative for illicit opioids with missing presumed positive (primary outcome) and (2) treatment retention at week 12 (secondary outcome). Poisson regression was used to estimate a risk ratio for no illicit opioid use calculated using Generalized Estimating Equations accounting for clusters. Retention rates were compared using Poisson regression with robust standard errors. Results: Of 114 patients screened, 78 (68.4%) enrolled: 20 (25.6%) female; 30 (38.5%) non-white; 65 (83.3%) graduated high school; and 31 (39.7%) reported homelessness. The mean (SD) number of days on medication before study enrollment was 8.96 (± 7.34). The mean (SD)/ median (IQR) for submitted videos was 31% (34%) and 16% (51%), respectively. In intention-to-treat analysis, the rate of weekly opioid negative UDT was 50% (95% CI 40-63%) in the intervention arm versus 64% (95% CI 55-74%) in the TAU arm; RR = 0.78 (95% CI 0.60-1.02, p = 0.07). Retention was similar in the intervention versus TAU arm, 69% (95% CI 56-86%) v. 82% (95% CI 71-95%); RR = 0.84 (95% CI 0.65-1.10, p = 0.20). Conclusion: Video DOT for recently enrolled office-based buprenorphine patients for 12 weeks did not suggest benefits on illicit opioid use and treatment retention. However, its effectiveness was limited by low rates of use. Background: The opioid epidemic continues to have devastating consequences. Buprenorphine is an effective treatment for opioid use disorder (OUD), but about half of patients drop out within the first year. Support persons (e.g., family members, close friends) of patients starting buprenorphine may encourage treatment retention. Community Reinforcement and Family Training (CRAFT) is an evidencebased approach developed as an individualized therapy for support persons (SP) of treatment-refusing substance users, but has not been extensively tested for OUD. We adapted CRAFT for support persons of patients starting buprenorphine and for delivery in a rolling, group format. To understand the feasibility and acceptability of this adaption, we assembled focus groups for feedback. Methods: Our research team convened two focus groups: (1) patients with OUD in buprenorphine treatment and (2) SP of patients in buprenorphine treatment. Participants received $50 remuneration. Themes were gathered and summarized, and feedback was incorporated in the final version of the intervention. Results: The patient group (N = 12 participants) highlighted the importance of their loved one understanding opioid addiction, buprenorphine benefits and side-effects, and how to administer Narcan. The SP group (N = 10 participants; partners, parents, grandparent, close friends) emphasized that the group filled a large gap in available clinical/support services for SPs and discussed the desire for more opioid education and training in communication. Perceived benefits of CRAFT included increased understanding of the patient's perspective, the trajectory of addiction and role of buprenorphine in recovery, and emotional support for SPs from group members. Feedback was incorporated into an adapted 10-session CRAFT manual that is currently being piloted. Conclusion: Focus group results suggest that group-based CRAFT may be a feasible and acceptable approach for broadening OUD treatment to include support persons. This approach has the potential to help retain patients in buprenorphine treatment while improving the SP and patient relationship.

A112
"Building a pathway to treatment: pilot-test of family connect, a linkage-to-substance use treatment program for youth on probation" (TD03) Gail N. Robson, Jacqueline Lee, Jillian Watkins, Gail Wasserman, and Katherine Elkington Lead Author Affiliation: Columbia University, 1051 Riverside Dr, New York, NY 10032, USA Correspondence: Katherine Elkington (ke2143@cumc.columbia.edu) Addict Sci Clin Pract 2020, 15(Suppl 2):A112 Background: Approximately 25%-50% of justice-involved youth (JIY) have substance use problems or disorders (SU/SUD), rates much higher than youth in the general population, yet 50%-80% of JIY do not receive SU services. Well-documented individual, family, and structural barriers must be addressed for JIY with SU/D to achieve linkage to services and ultimately, positive behavioral health outcomes.
We developed and pilot-tested a unique service delivery model (Family CONNECT) that targets family-and systems-level factors to increase uptake of SU services among JIY. Methods: We enrolled n = 18 youth on probation in need of SU treatment (56% male, age 14.49 years, 28% white, 44% Hispanic), and their caregivers, into Family Connect. Families worked with a linkage specialist (LS) to facilitate engagement in treatment; the LS also coordinated with probation officers and treatment providers. Referral, initiation (intake) and treatment engagement (intake + 1 session) of Family CONNECT youth was compared to a historical control group drawn from probation records using chi2 and multivariable logistic regression. Results: Rates of referral [94% vs 74%, non-significant (ns)] and initiation (88% vs 71%, ns) to any behavioral health services were higher in Family CONNECT, while treatment engagement (56% vs 61%, ns) was slightly lower in Family CONNECT youth. On average, LS spent 90 days working with families to initiate treatment. Logistic regression models showed no demographic differences in initiation and engagement in care, and for referral only case type (JD vs PINS) was significant (OR = 3.3 [1.1, 9.8], p < 0.05) with more PINS referred for treatment. Conclusion: Family Connect demonstrated promise of efficacy to successfully move JIY through the behavioral health care cascade, achieving increased referral and intake and similar levels of engagement. Use of a LS is a feasible approach to overcome both system-and youth/ family-level factors to increase treatment uptake in JIY.