Major Gaps in the Cascade of Care for Opioid Use Disorder: Implications for Clinical Practice.

This Viewpoint examines a recent report that used data from the 2022 National Survey on Drug Use and Health to estimate the opioid cascade of care, a framework to characterize the adult US populations who needed and received opioid use disorder (OUD) treatment, as well as discusses ways in which clinicians can close gaps in care.

Estimated Number of Children Who Lost a Parent to Drug Overdose in the US From 2011 to 2021.

Importance: Parents' overdose death can have a profound short- and long-term impact on their children, yet little is known about the number of children who have lost a parent to drug overdose in the US. Objective: To estimate the number and rate of children who have lost a parent to drug overdose from 2011 to 2021 overall and by parental age, sex, and race and ethnicity. Design, Setting, and Participants: This was a cross-sectional study of US community-dwelling persons using data from the National Survey on Drug Use and Health (2010-2014 and 2015-2019) and the National Vital Statistics System (2011-2021). Data were analyzed from January to June 2023. Exposure: Parental drug overdose death, stratified by age group, sex, and race and ethnicity. Main Outcomes and Measures: Numbers, rates, and average annual percentage change (AAPC) in rates of children losing a parent aged 18 to 64 years to drug overdose, overall and by age, sex, and race and ethnicity. Results: From 2011 to 2021, 649 599 adults aged 18 to 64 years died from a drug overdose (mean [SD] age, 41.7 [12.0] years; 430 050 [66.2%] male and 219 549 [33.8%] female; 62 606 [9.6%] Hispanic, 6899 [1.1%] non-Hispanic American Indian or Alaska Native, 6133 [0.9%] non-Hispanic Asian or Pacific Islander, 82 313 [12.7%] non-Hispanic Black, 485 623 [74.8%] non-Hispanic White, and 6025 [0.9%] non-Hispanic with more than 1 race). Among these decedents, from 2011 to 2021, an estimated 321 566 (95% CI, 276 592-366 662) community-dwelling children lost a parent aged 18 to 64 years to drug overdose. The rate of community-dwelling children who lost a parent to drug overdose per 100 000 children increased from 27.0 per 100 000 in 2011 to 63.1 per 100 000 in 2021. The highest rates were found among children of non-Hispanic American Indian or Alaska Native individuals, who had a rate of 187.1 per 100 000 in 2021, more than double the rate among children of non-Hispanic White individuals (76.5 per 100 000) and non-Hispanic Black individuals (73.2 per 100 000). While rates increased consistently each year for all parental age, sex, and race and ethnicity groups, non-Hispanic Black parents aged 18 to 25 years had the largest AAPC (23.8%; 95% CI, 16.5-31.6). Rates increased for both fathers and mothers; however, more children overall lost fathers (estimated 192 459; 95% CI, 164 081-220 838) than mothers (estimated 129 107; 95% CI, 112 510-145 824). Conclusions and Relevance: An estimated 321 566 children lost a parent to drug overdose in the US from 2011 to 2021, with significant disparities evident across racial and ethnic groups. Given the potential short- and long-term negative impact of parental loss, program and policy planning should ensure that responses to the overdose crisis account for the full burden of drug overdose on families and children, including addressing the economic, social, educational, and health care needs of children who have lost parents to overdose.

Recovery-Oriented Systems of Care: A Perspective on the Past, Present, and Future.

This paper provides a perspective on the recent concept of recovery-oriented systems of care with respect to its origins in the past and its status in the present, prior to considering directions in which such systems might move in the future. Although influential in practice, this concept has yet to be evaluated empirically and has not been the object of a review. Recovery-oriented systems of care emerged from the efforts of persons with mental health and/or substance use disorders who advocated for services to go beyond the reduction of symptoms and substance use to promote a life in the community. Subsequent efforts were made to delineate the nature and principles of such services and those required of a system of such care. Coincident with the U.S. Substance Abuse and Mental Health Services Administration dropping reference to behavioral health in its revised definition of recovery, confusions and limitations began to emerge. Recovery appeared to refer more to a process of self-actualization for which an individual is responsible than to a process of healing from the effects of a behavioral health condition and associated stigma. In response, some systems are aiming to address social determinants of behavioral health conditions that transcend the scope of the individual and to develop a citizenship-oriented approach to promote community inclusion.

The Organizational Multicultural Competence Assessment (OMCA): A tool to assess an organization's multicultural competence and adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (the National CLAS Standards).

Objective: Behavioral health organizations must respond to the needs of increasing numbers of multicultural populations, as the world population continues to diversify. The goal of this research was to develop a measure to assess the multicultural competence of a behavioral health agency using a quick and efficient but comprehensive strategy that utilizes input from multiple staff members. Method: The Organizational Multicultural Competence Assessment (OMCA) was developed through a review of existing cultural competence assessment measures and item generation from researchers and policy makers. 469 staff from all departments of a U.S. state-operated and funded behavioral health facilities were asked by the CEO of their agency to complete the 45-item survey. Findings: Principal components analysis revealed seven factors that accounted for 64% of the variance in item responses: Governance, Policies, and Procedures; Staff Training and Service Delivery; Addressing Stigma and Discrimination; Accessibility of Services; Community Relationships; Quality, Monitoring, and Evaluation; and Human Resource Development. Items within factors showed high internal reliability. Conclusions and Implications for Practice: This measure may be used on an ongoing basis as a quality improvement tool to assess an agency or system's multicultural competence and adherence to the CLAS standards. Future research can investigate the relationship between scores on this measure and organization-level recovery oriented, client health, and person-centered outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Enhancing outcomes for persons with co-occurring disorders through skills training and peer recovery support.

Background: "Recovery supports", often provided by persons in recovery themselves, have emerged over the last decade as important components of recovery-oriented systems of care for persons with substance use disorders.Aims: This study assesses the benefit of adding peer recovery supports to the care of adults with co-occurring psychosis and substance use.Method: 137 adults with both disorders who had at least one prior admission within the past year were recruited during an index hospitalization into a randomized trial of standard care vs skills training with and without a peer-led social engagement program. Participants were assessed at admission and at three and nine months post-discharge on symptoms, functioning, substance use, and other factors.Results: At three months, skills training was effective in reducing alcohol use and symptoms, with the addition of peer-led support resulting in higher levels of relatedness, self-criticism, and outpatient service use. At nine months, skills training was effective in decreasing symptoms and inpatient readmissions and increasing functioning, with the addition of peer support resulting in reduced alcohol use.Conclusions: Adding peer-led support may increase engagement in care over the short term and reduce substance use over the longer-term for adults with co-occurring disorders.

Racial and Ethnic Differences in Use of State-Operated Inpatient Substance Abuse Services, 2004-2005 Versus 2010-2011.

OBJECTIVE: This study examined ethnic-racial differences in referral source, length of stay, legal status, and diagnosis in state-operated substance abuse inpatient treatment in Connecticut. METHODS: Data from 2004-2005 (N=1,484) and from 2010-2011 (N=4,529) were investigated with regression analyses. RESULTS: At both time points, African Americans were more likely than other groups to be referred by criminal justice sources, Hispanics were more likely than whites to be referred by other sources, and whites were more likely than African Americans to have emergency-crisis admissions; length of stay was shorter for Hispanics than for whites and longer for African Americans than for whites and Hispanics; and Hispanics were less likely than other groups to have an alcohol use disorder, more likely than other groups to have a drug use disorder, and more likely than whites to receive a discharge diagnosis of a personality disorder from cluster B. CONCLUSIONS: Targeted interventions to address racial-ethnic differences in inpatient addiction treatment are needed.

An Evaluation of Racial and Ethnic Health Differences in State Mental Health Inpatient Services: 2002-2005 Versus 2010-2011.

This study analyzed racial-ethnic differences previously documented in the Connecticut Department of Mental Health and Addiction Services mental health inpatient system across two time periods (2002-2005 and 2010-2011). Comparisons of logistic regression analyses from the two time periods showed that, at time 1, significant racial-ethnic differences were found for referral by other sources (e.g., outpatient), length of stay, discharge against medical advice, and some diagnostic differences (e.g., schizophrenia, other psychotic disorders, cluster B discharge diagnosis), but these differences were not significant at time 2. Other diagnostic differences remained significant at time 2 (e.g., mood disorders, substance use disorders, other axis I disorders, mental retardation) as well as racial-ethnic differences in self-referral. These results suggest that the multiple national and state cultural competence initiatives between time 1 and time 2 could have resulted in decreases in racial-ethnic differences. Targeted interventions to alleviate the remaining differences are needed.

The Connecticut Mental Health Center: Celebrating 50 Years of a Successful Partnership Between the State and Yale University.

September 28, 2016, marked the 50th anniversary of the Connecticut Mental Health Center, a state-owned and state-operated joint venture between the state and Yale University built and sustained with federal, state, and university funds. Collaboration across these entities has produced a wide array of clinical, educational, and research initiatives, a few of which are described in this column. The missions of clinical care, research, and education remain the foundation for an organization that serves 5,000 individuals each year who are poor and who experience serious mental illnesses and substance use disorders.

Learning from those we serve: Piloting a culture competence intervention co-developed by university faculty and persons in recovery.

OBJECTIVE: This article describes the development and piloting of a bilevel intervention codeveloped by persons in recovery from mental illness and addiction and university faculty with expertise in cultural competence to improve the cultural competence of a community mental health center in the northeastern United States. METHOD: Two faculty and 5 persons in recovery met for 6 months to develop the bilevel training intervention. They discussed experiences of culturally responsive care and developed experiential activities and case examples for the 2-day training. Forty-five community mental health service providers attended the 2-day training. Trainees' self-reported awareness, knowledge, and skills in cultural competence were measured pre and post training and analyzed with repeated measure t tests. Next, faculty and persons in recovery provided follow-up training and helped to establish an infrastructure supported to support the agency cultural competence plan. One hundred twenty-five providers completed the Organizational Multicultural Competence Survey and between-subjects t tests measured increases in organizational cultural competence. RESULTS: Significant increases were found in providers' multicultural knowledge, awareness, and skills. Qualitative responses demonstrated the contribution of the experiences of persons in recovery to the training. Ratings of the organizational-level cultural competence intervention showed significant improvements in the agency's cultural competence policies (e.g., implementation of strategies to hire and retain a diverse workforce). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These data suggest that bilevel interventions codeveloped by persons in recovery and researchers may be effective in increasing provider and organizational-level cultural competence. Future research should evaluate the effect of these interventions on consumers and health outcomes.

Racial-ethnic differences in access, diagnosis, and outcomes in public-sector inpatient mental health treatment.

This study investigated inequities in access, diagnosis, and treatment for African Americans and Hispanic Americans receiving treatment in northeast, public sector, inpatient mental health settings as part of a Department of Mental Health and Addiction Services Health Disparities Initiative. Data from 1,484 adults were obtained through a random extract of patients admitted to state inpatient facilities between 2002 and 2005. After controlling for demographic variables and symptom severity, logistic and linear regression showed that Hispanic Americans were significantly more likely to enter inpatient care through crisis/emergency sources and were significantly less likely to self-refer or come to inpatient care through other sources (e.g., family, outpatient). After admission, Hispanic Americans were more likely to be diagnosed with other psychotic disorders (e.g., schizoaffective disorder, delusional disorder), were less likely to receive an Axis II diagnosis at discharge, and had a shorter length of stay than non-Hispanic White Americans. African Americans were more likely than other groups to be diagnosed with schizophrenia, drug-related, and Cluster B diagnoses (discharge only), and they were less likely to be diagnosed with mood disorders and other nonpsychotic disorders. Although African Americans were more likely than other groups to come to inpatient units from numerous routes, including self-referral and referral from other sources (e.g., family, outpatient), they were more likely to terminate treatment against medical advice and displayed shorter length of stay despite receiving ratings of greater symptom severity at discharge. These findings highlight the need for policies, programs, and system interventions designed to eliminate disparities and improve the quality and cultural responsiveness of behavioral health services.

Peer recovery support for individuals with substance use disorders: assessing the evidence.

In recent years, peer recovery support services have become an accepted part of the treatment of substance use disorders, providing a more extensive array of services than typically associated with mutual support groups. Peer providers may help consumers set recovery goals, develop a plan, and work toward and maintain recovery. In this literature review, the last in the Assessing the Evidence Base (AEB) Series, the authors review the evidence supporting peer recovery support services, noting that more research is needed to distinguish the effects of peer recovery support from other recovery support activities.

Skill building: assessing the evidence.

OBJECTIVE: Skill building for adults involves multiple approaches to address the complex problems related to serious mental illness. Individuals with schizophrenia are often the research focus. The authors outline key skill-building approaches and describe their evidence base. METHODS: Authors searched meta-analyses, research reviews, and individual studies from 1995 through March 2013. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: Over 100 randomized controlled trials and numerous quasi-experimental studies support rating the level of evidence as high. Outcomes indicate strong effectiveness for social skills training, social cognitive training, and cognitive remediation, especially if these interventions are delivered through integrated approaches, such as Integrated Psychological Therapy. Results are somewhat mixed for life skills training (when studied alone) and cognitive-behavioral approaches. The complexities of schizophrenia and other serious mental illnesses call for individually tailored, multimodal skill-building approaches in combination with other treatments. CONCLUSIONS: Skill building should be a foundation for rehabilitation services covered by comprehensive benefit plans that attend to the need for service packages with multiple components delivered in various combinations. Further research should demonstrate more conclusively the long-term effectiveness of skill building in real-life situations, alone and in various treatment combinations. Studies of diverse subpopulations are also needed.

Trauma-focused cognitive-behavioral therapy for children and adolescents: assessing the evidence.

OBJECTIVE: Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a conjoint parent-child treatment developed by Cohen, Mannarino, and Deblinger that uses cognitive-behavioral principles and exposure techniques to prevent and treat posttraumatic stress, depression, and behavioral problems. This review defined TF-CBT, differentiated it from other models, and assessed the evidence base. METHODS: Authors reviewed meta-analyses, reviews, and individual studies (1995 to 2013). Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, PILOTS, the ERIC, and the CINAHL. They chose from three levels of research evidence (high, moderate, and low) on the basis of benchmarks for number of studies and quality of their methodology. They also described the evidence of effectiveness. RESULTS: The level of evidence for TF-CBT was rated as high on the basis of ten RCTs, three of which were conducted independently (not by TF-CBT developers). TF-CBT has demonstrated positive outcomes in reducing symptoms of posttraumatic stress disorder, although it is less clear whether TF-CBT is effective in reducing behavior problems or symptoms of depression. Limitations of the studies include concerns about investigator bias and exclusion of vulnerable populations. CONCLUSIONS: TF-CBT is a viable treatment for reducing trauma-related symptoms among some children who have experienced trauma and their nonoffending caregivers. Based on this evidence, TF-CBT should be available as a covered service in health plans. Ongoing research is needed to further identify best practices for TF-CBT in various settings and with individuals from various racial and ethnic backgrounds and with varied trauma histories, symptoms, and stages of intellectual, social, and emotional development.

Peer support services for individuals with serious mental illnesses: assessing the evidence.

OBJECTIVE: This review assessed the level of evidence and effectiveness of peer support services delivered by individuals in recovery to those with serious mental illnesses or co-occurring mental and substance use disorders. METHODS: Authors searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature for outcome studies of peer support services from 1995 through 2012. They found 20 studies across three service types: peers added to traditional services, peers in existing clinical roles, and peers delivering structured curricula. Authors judged the methodological quality of the studies using three levels of evidence (high, moderate, and low). They also described the evidence of service effectiveness. RESULTS: The level of evidence for each type of peer support service was moderate. Many studies had methodological shortcomings, and outcome measures varied. The effectiveness varied by service type. Across the range of methodological rigor, a majority of studies of two service types--peers added and peers delivering curricula--showed some improvement favoring peers. Compared with professional staff, peers were better able to reduce inpatient use and improve a range of recovery outcomes, although one study found a negative impact. Effectiveness of peers in existing clinical roles was mixed. CONCLUSIONS: Peer support services have demonstrated many notable outcomes. However, studies that better differentiate the contributions of the peer role and are conducted with greater specificity, consistency, and rigor would strengthen the evidence.

Residential treatment for individuals with substance use disorders: assessing the evidence.

OBJECTIVE: Residential treatment is a commonly used direct intervention for individuals with substance use or co-occurring mental and substance use disorders who need structured care. Treatment occurs in nonhospital, licensed residential facilities. Models vary, but all provide safe housing and medical care in a 24-hour recovery environment. This article describes residential treatment and assesses the evidence base for this service. METHODS: Authors evaluated research reviews and individual studies from 1995 through 2012. They searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Social Services Abstracts. They chose from three levels of evidence (high, moderate, and low) and described the evidence of service effectiveness. RESULTS: On the basis of eight reviews and 21 individual studies not included in prior reviews, the level of evidence for residential treatment for substance use disorders was rated as moderate. A number of randomized controlled trials were identified, but various methodological weaknesses in study designs-primarily the appropriateness of the samples and equivalence of comparison groups-decreased the level of evidence. Results for the effectiveness of residential treatment compared with other types of treatment for substance use disorders were mixed. Findings suggested either an improvement or no difference in treatment outcomes. CONCLUSIONS: Residential treatment for substance use disorders shows value and merits ongoing consideration by policy makers for inclusion as a covered benefit in public and commercially funded plans. However, research with greater specificity and consistency is needed.

Substance abuse intensive outpatient programs: assessing the evidence.

OBJECTIVE: Substance abuse intensive outpatient programs (IOPs) are direct services for people with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. IOPs are alternatives to inpatient and residential treatment. They are designed to establish psychosocial supports and facilitate relapse management and coping strategies. This review assessed the evidence base for IOPs. METHODS: Authors searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. They identified 12 individual studies and one review published between 1995 and 2012. They chose from three levels of research evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described evidence of service effectiveness. RESULTS: Based on the quality of trials, diversity of settings, and consistency of outcomes, the level of evidence for IOPs was rated high. Multiple randomized trials and naturalistic analyses that compared IOPs with inpatient or residential care found comparable outcomes. All studies reported reductions in alcohol and drug use. However, substantial variability in the operationalization of IOPs and outcome measures was apparent. CONCLUSIONS: IOPs are an important part of the continuum of care for substance use disorders. They are as effective as inpatient treatment for most individuals. Public and commercial health plans should consider IOP services as a covered health benefit. Standardization of the elements included in IOPs may improve their quality and effectiveness.

Consumer and family psychoeducation: assessing the evidence.

OBJECTIVE: Psychoeducation provides adult consumers who have serious mental illness or co-occurring substance use disorders with information to support recovery. Some models also provide this service to family members. This review examined the evidence base for psychoeducation models in group and individual formats. METHODS: Authors reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described service effectiveness. RESULTS: More than 30 randomized controlled trials (RCTs) of consumer psychoeducation and more than 100 RCTs of family psychoeducation provide a high level of evidence for the effectiveness of each model. Reviews of consumer psychoeducation found that experimental groups had reduced nonadherence (primarily with medication regimens), fewer relapses, and reduced hospitalization rates compared with control groups. Some studies found significant improvements in social and global functioning, consumer satisfaction, and quality of life. Multifamily psychoeducation groups (the focus of numerous studies) were associated with significantly improved problem-solving ability and a reduced burden on families, compared with control groups, among other strong outcome effects. CONCLUSIONS: Psychoeducation should be included in covered services. Group and family interventions are especially powerful. Future research should assess psychoeducation models with children and adolescents and with individuals from various racial and ethnic backgrounds.

Behavioral management for children and adolescents: assessing the evidence.

OBJECTIVE: Behavioral management services for children and adolescents are important components of the mental health service system. Behavioral management is a direct service designed to help develop or maintain prosocial behaviors in the home, school, or community. This review examined evidence for the effectiveness of family-centered, school-based, and integrated interventions. METHODS: Literature reviews and individual studies published from 1995 through 2012 were identified by searching PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: The level of evidence for behavioral management was rated as high because of the number of well-designed randomized controlled trials across settings, particularly for family-centered and integrated family- and school-based interventions. Results for the effectiveness of behavioral management interventions were strong, depending on the type of intervention and mode of implementation. Evidence for school-based interventions as an isolated service was mixed, partly because complexities of evaluating group interventions in schools resulted in somewhat less rigor. CONCLUSIONS: Behavioral management services should be considered for inclusion in covered plans. Further research addressing the mechanisms of effect and specific populations, particularly at the school level, will assist in bolstering the evidence base for this important category of clinical intervention.

Permanent supportive housing: assessing the evidence.

OBJECTIVES: Permanent supportive housing provides safe, stable housing for people with mental and substance use disorders who are homeless or disabled. This article describes permanent supportive housing and reviews research. METHODS: Authors reviewed individual studies and literature reviews from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. The authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: The level of evidence for permanent supportive housing was graded as moderate. Substantial literature, including seven randomized controlled trials, demonstrated that components of the model reduced homelessness, increased housing tenure, and decreased emergency room visits and hospitalization. Consumers consistently rated this model more positively than other housing models. Methodological flaws limited the ability to draw firm conclusions. Results were stronger for studies that compared permanent supportive housing with treatment as usual or no housing rather than with other models. CONCLUSIONS: The moderate level of evidence indicates that permanent supportive housing is promising, but research is needed to clarify the model and determine the most effective elements for various subpopulations. Policy makers should consider including permanent supportive housing as a covered service for individuals with mental and substance use disorders. An evaluation component is needed to continue building its evidence base.