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PREPUBLICATION COPY: UNCORRECTED PROOFS MEASURING SUCCESS IN SUBSTANCE USE GRANT PROGRAMS: OUTCOMES AND METRICS FOR IMPROVEMENT Committee on the Review of Specific Programs in the Comprehensive Addiction and Recovery Act Board on Population Health and Public Health Practice Health and Medicine Division A Consensus Study Report of
PREPUBLICATION COPY: UNCORRECTED PROOFS THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by a contract between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25745 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Measuring success in substance use grant programs: Outcomes and metrics for improvement. Washington, DC: The National Academies Press. https://doi.org/10.17226/25745.
PREPUBLICATION COPY: UNCORRECTED PROOFS The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.
PREPUBLICATION COPY: UNCORRECTED PROOFS Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the studyâs statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committeeâs deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.
PREPUBLICATION COPY: UNCORRECTED PROOFS v COMMITTEE ON THE REVIEW OF SPECIFIC PROGRAMS IN THE COMPREHENSIVE ADDICTION AND RECOVERY ACT KENNETH B. WELLS (Chair), Director, Center for Health Services and Society, Semel Institute, University of California, Los Angeles HORTENSIA AMARO (Vice Chair), Distinguished University Professor and Senior Scholar on Community Health, Florida International University GINA BRYAN, Director, Post Graduate Psych-Mental Health Program, Clinical Professor, University of WisconsinâMadison KAREN CROPSEY, Conaster Turner Endowed Professor of Psychiatry, University of Alabama at Birmingham JOAN DUWVE, Associate Professor and Associate Dean of Public Health Practice, Fairbanks School of Public Health, Indiana University RAHUL GUPTA, Senior Vice President and Chief Medical and Health Officer, March of Dimes DAVID GUSTAFSON, Director, Center for Health Enhancement Systems Studies, University of WisconsinâMadison MARCELA HORVITZ-LENNON, Senior Physician Policy Researcher, RAND Corporation RAYMOND LOVE, Professor and Vice Chair, State of Maryland Mental Health Pharmacy Program, University of Maryland School of Pharmacy YNGVILD OLSEN, Medical Director, REACH Health Services, Institutes for Behavior Resources, Inc. SHARON REIF, Senior Scientist and Lecturer, Heller School for Social Policy and Management, Brandeis University Study Staff KATHLEEN STRATTON, Scholar ANDREW MERLUZZI, Program Officer AIMEE MEAD, Associate Program Officer ALEXIS WOJTOWICZ, Research Associate MISRAK DABI, Financial Business Partner ROSE MARIE MARTINEZ, Senior Board Director
PREPUBLICATION COPY: UNCORRECTED PROOFS vii Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: KARA ODOM WALKER, Delaware Health and Social Services MIRIAM KOMAROMY, Boston Medical Center KATHLENE TRACY, Icahn School of Medicine at Mount Sinai KENNETH W. KIZER, Atlas Research, LLC CHIN HWA (GINA) DAHLEM, University of Michigan School of Nursing MOLLY BROWN, DePaul University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by JACK C. EBELER, Health Policy Alternatives, Inc and JODY D. RICH, Brown University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
PREPUBLICATION COPY: UNCORRECTED PROOFS ix Contents ACKNOWLEDGEMENTS xi PREFACE xii SUMMARY S-1 1 INTRODUCTION AND BACKGROUND 1-1 2 PREVENTION PROGRAMS 2-1 3 TREATMENT PROGRAMS 3-1 REFERENCES R-1 APPENDIXES A PUBLIC MEETING AGENDAS A-1 B COMMITTEE BIOGRAPHICAL SKETCHES B-1
PREPUBLICATION COPY: UNCORRECTED PROOFS xi Acknowledgments The committee of this study thanks Dr. Tara Benjamin for her service in the early phases of this report. The committee also thanks the Comprehensive Addiction and Recovery Act (CARA) grantees for their work and for providing information to the National Academies for this study.
PREPUBLICATION COPY: UNCORRECTED PROOFS xiii Preface Substance use disorder (SUD), and opioid use disorder (OUD) in particular, is a significant public health concern in the United States. Drug overdose events and overdose deaths are a national crisis. Health systems and community infrastructures have struggled to adequately respond over a range of prevention, treatment, retention/recovery, and dissemination strategies. Deaths due to opioids number in the tens of thousands every year. Overdose is all too common, particularly given the recent influx of highly potent opioids, such as fentanyl, and the increase of opioid use with benzodiazepines. In addition, treatment for OUD can be challenging to implement, given issues such as lack of client engagement and retention in treatment, lack of access to treatment, social stigma, lack of integration with other services, and financing challenges. In 2016, the United States Congress authorized and appropriated funding to fight the opioid epidemic through the Department of Health and Human Services (HHS). Among other initiatives, the Comprehensive Addiction and Recovery Act (CARA) gave the Substance Abuse1 and Mental Health Services Administration (SAMHSA) authority and support to implement new grant programs focused on preventing overdose and treating individuals with OUD, including for high-risk populations, such as pregnant women. This Consensus Study is the first in a series of reports to evaluate the success of several CARA grant programs. This report focuses on reviewing and recommending changes or additions to outcome measures to enhance evaluation of the programs. The committee authoring this report gathered evidence from existing grantees and the broader literature to consider SAMHSAâs existing outcome measures and priorities. Then, given the goals of the CARA grant programs, the committee developed recommendations about metrics and outcomes that would improve the nationâs ability to measure the impact of these important programs. Recognizing that individual service delivery programs may not have the staff or resources to implement large- scale data collection and evaluation and that the funds available to use on data-collection processes through the grants are limited, the metrics and outcomes in this report represent the committeeâs view on practical, implementable, and useful ideas for reducing overdose events and enhancing recovery for people who use opioids. We also note that SAMSHA has a substantial history of funding programs and evaluations in this area with publicly available outcome and impact measures. While acknowledging those strengths, we seek to assure that a range of important outcomes can be identified within and across these programs. As chair and vice chair, we thank our fellow committee members for their work on this report, their input and expertise, and their commitment to improving the publicâs health. The committee would also like to express its appreciation to SAMHSA for sponsoring this program as well as other programs to address substance use generally and the opioid crisis in particular. 1 Where possible, the committee has used non-stigmatizing language throughout this report, such as âuseâ rather than âabuse,â âmedications for opioid use disorderâ rather than âmedication-assisted treatment,â and âoverdose survivorsâ rather than âoverdose victimsâ as has been the custom in recent scholarship on this topic (NASEM, 2020).
PREPUBLICATION COPY: UNCORRECTED PROOFS xiv Sincere gratitude is given to the individual grantees that have provided their goals and evaluation strategies for implementing activities under the SAMHSA grant programsâthese are the individuals and organizations seeking to improve the publicâs health every day. In addition, the committee could not have completed this report without the guidance and dedication of the National Academies staff who shepherded it through to its conclusion. We thank Kathleen Stratton, Andrew Merluzzi, Aimee Mead, Alexis Wojtowicz, Misrak Dabi, and Rose Marie Martinez. We hope that our recommendations can help both the grantees and SAMSHA advance their work to address the SUD crisis affecting our nationâs health and assure that the impacts of the programs can be identified, interpreted, and built upon. Kenneth B. Wells (Chair) Hortensia Amaro (Vice Chair) Committee on the Review of Specific Programs in the Comprehensive Addiction and Recovery Act