3

Treatment Programs

INTRODUCTION

Two of the Comprehensive Addiction and Recovery Act (CARA) grant programs—Building Communities of Recovery (BCOR) and the State Pilot Grant Program for Treatment for Pregnant and Postpartum Women (PPW-PLT)—are focused on substance use disorder (SUD) treatment. This chapter provides an overview of these two programs, the outcomes and metrics that they require from grantees, and the committee’s recommendations for outcomes and metrics that grantees should collect and report in order to meet the goals of each grant program.

BCOR

The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT) began accepting applications for the BCOR program in fiscal year (FY) 2017. BCOR is intended to bolster communities’ support systems for substance use and addiction. Specifically, the grant’s aim is to support “the development, enhancement, expansion, and delivery of recovery support services (RSS) as well as promotion of and education about recovery.”¹

To be eligible for BCOR funding, a potential awardee must be a registered 501(c)(3) and—to ensure appropriate representation—must be led

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¹ See https://www.samhsa.gov/grants/grant-announcements/ti-19-003 (accessed March 13, 2020).

and governed by individuals within the local communities of recovery. In the original CARA legislation, grants were made available for up to 3 years at a maximum of $200,000 per year. Importantly, as was written in the original CARA legislation, BCOR grantees must receive at least 50 percent of their funding for the proposed project from non-federal sources. CARA appropriated $1 million per year for BCOR grants for 2017 through 2021.²

SAMHSA funded eight grantees in FY2017 for up to $200,000 annually with a 100 percent matching requirement. SAMHSA funded an additional 18 grantees in FY2018 with off-the-shelf funding. Some of these most recent grantees have also received other SAMHSA peer-to-peer grants and therefore have existing infrastructure to work with; other grantees are new to SAMHSA.³

The BCOR program requires that grantees use the funding to “develop, expand, and enhance community and statewide” RSS. This could include a wide range of activities related to RSS, such as building connections between different recovery resources and networks, reducing stigma associated with drug and alcohol use, providing educational programming and outreach related to drug and alcohol use and recovery, providing peer mentorship and coaching, or linking to other service providers.

Other allowable activities include building infrastructural connections between substance use treatment programs, primary care providers, the criminal legal system, employers, housing services, child welfare agencies, or other RSS that promote recovery from SUD; designing activities to reduce stigma; or conducting public education, training, and outreach on identifying SUD and promoting a culture of support and recovery. Table 3-1 shows a summary of the BCOR program.

Grantees in the BCOR program are required to collect and report two primary sets of outcomes and metrics. The first is the CSAT Government Performance Results and Modernization Act (GPRA) of 2010 tool (described in more detail in Box 3-3). The second required set of metrics pertains to infrastructure activities and includes proxies for whether community and statewide RSS has been expanded or enhanced:

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² In October 2018, the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (P.L. 115-271 or the SUPPORT for Patients and Communities Act) was signed into law. This law amended various components of CARA, including changing the limits on the federal share of the costs that a program could use to 85 percent from the original 50 percent. In addition, the SUPPORT Act increased the appropriations to BCOR from $1 million per year to $5 million per year for each year from 2019 through 2023 (see https://fas.org/sgp/crs/misc/R45423.pdf [accessed March 12, 2020]).

³ See https://www.samhsa.gov/grants/awards/2018/TI-17-015 (accessed April 21, 2020).

TABLE 3-1 Summary of the BCOR Program

^a See https://www.samhsa.gov/grants/grant-announcements/ti-19-003 (accessed March 13, 2020).

^b See https://www.samhsa.gov/grants/awards/2017/TI-17-015 (accessed April 21, 2020).

^c See https://www.samhsa.gov/grants/awards/2018/TI-17-015 (accessed April 21, 2020).

• The number of Training/Technical Assistance (T/TA) events held;
• The number of participants in attendance;
• Satisfaction with the grantee’s knowledge sharing T/TA in the event; and
• Usefulness of the information provided during the T/TA event.

Lastly, grantees are required to conduct and report a local performance assessment at least once per year. This assessment is designed to promote continual grantee improvement and help grantees determine whether they are meeting their goals, objectives, and outcomes, including on behavioral health disparities. Grantees are allowed to use up to 20 percent of the federal funding for data collection, performance measurement, and performance assessment. Box 3-1 shows the current program grantees.

PPW-PLT

Similar to BCOR, SAMHSA’s CSAT began accepting applications for the PPW-PLT program in FY2017. PPW-PLT aims to

SAMHSA’s overall goal with respect to the PPW-PLT program is to reduce use of alcohol and other drugs, increase engagement and retention in treatment, and increase access to and use of medications to treat substance use disorders.

Of note, the PPW-PLT is distinct from another grant program offered by SAMHSA, the Services Grant Program for Residential Treatment for Pregnant and Postpartum Women, which focuses exclusively on residential treatment, prevention, and recovery services for women and their children.⁵ Grantees under the PPW-PLT program, on the other hand, may only use up to 15 percent of funds on residential-based services (though they are not required to provide residential-based services under the terms of the grant).

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⁴ See https://www.samhsa.gov/grants/grant-announcements/ti-20-010 (accessed March 13, 2020).

⁵ See https://www.samhsa.gov/grants/grant-announcements/ti-17-007 (accessed March 13, 2020).

To be eligible for PPW-PLT funding, a potential awardee must be a Single State Agency (SSA) for Substance Abuse. These SSAs are required to partner with at least one direct service provider organization (e.g., a substance use treatment organization) that meets the following criteria: is appropriate to the grant and directly involved in the proposed project; has been providing relevant services for at least the past 2 years; and is in compliance with all local and state licensing, accreditation, and certification requirements. A minimum of 75 percent of the awards were allocated to providing services either by the SSA or through partner organization(s).

No more than 25 percent was allowed for infrastructure development or an increase in statewide capacity to improve care for PPW.

Massachusetts, New York, and Virginia were funded in FY2017 (ending in 2020), and Georgia, North Carolina, and Tennessee were funded in FY2018 (ending in 2021). In the original CARA legislation, three grants were to be made available for up to 3 years and at a maximum of $1.1 million per grant. No cost sharing or matching was required for the PPW-PLT grants.⁶ The required activities under PPW-PLT are to:

• Facilitate the availability of family-based services for PPW, their minor children, and other family members as necessary, including outreach, engagement, screening, assessment, wrap-around recovery services, family reunification programs, parenting interventions, treatment for SUD with medication, mental health care, and case management;
• Promote the coordination of services across disparate systems (e.g., behavioral health, primary care, housing, child and family services); and
• Identify gaps in service availability throughout the state and implement a state infrastructure development plan to ensure sustained partnerships between existing public health systems and other state systems that could provide services across the continuum of care for PPW.

Other activities that are allowed under the PPW-PLT grant but are not required include updating information management systems to document and track client outcomes, training or developing the state mental health and SUD treatment workforce, and developing policy to improve the state’s ability to provide SUD services. Table 3-2 shows a summary of the PPW-PLT program.

Grantees in the PPW-PLT program are required to collect and report two primary sets of outcomes and metrics. The first is the CSAT GPRA tool (described in more detail in Box 3-3). The second required set of metrics pertains to the PPW-PLT program more specifically and includes a behavioral health diagnosis screening, a question about how treatment has influenced parenting/family responsibilities, a question about diagnosis of alcohol use disorder or opioid use disorder (OUD), and medication, if any, used to treat these disorders.

Lastly, grantees are required to conduct and report a local performance assessment at least once per year. This is designed to promote con-

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⁶ Unlike the BCOR program, the SUPPORT Act did not appropriate any additional funds to the PPW-PLT program (see https://fas.org/sgp/crs/misc/R45423.pdf [accessed March 12, 2020]).

TABLE 3-2 Summary of the PPW-PLT Program

^a See https://www.samhsa.gov/grants/grant-announcements/ti-20-010 (accessed March 13, 2020).

tinual grantee improvement and help grantees determine whether they are meeting their goals, objectives, and outcomes, including on behavioral health disparities. Grantees are allowed to use up to 15 percent of the federal funding for data collection, performance measurement, and performance assessment. Box 3-2 shows current program grantees.

RECOMMENDATIONS

Recognizing that the CSAT GPRA is not intended to be a clinical tool and that grantees may be limited in resources, there are several overarching themes that SAMHSA could incorporate into its collection and reporting of data from PPW-PLT and BCOR grantees (see Box 3-3). Given that PPW-PLT and BCOR grantees may not use more than 15 or 20 percent, respectively, of the grant funding for data collection and performance assessment, it may be helpful for SAMHSA’s internal evaluation teams to further collaborate to help grantees frame their evaluation questions and design, including their strategies for recruitment, engagement, retention, and follow-up assessment. Many community service delivery organizations will not have expertise in evaluation and may benefit from this guidance.

Care Delivery and Recovery Services

There is evidence that trauma-informed care is important for patients with SUD (Amaro et al., 2007b; McCauley et al., 2012; Roberts et al., 2015). For those with a history of military deployment, there is a screening question

for PTSD on the CSAT GPRA tool. However, for those who have never served in the military, screening for exposure to traumatic events or adverse childhood experiences is not thoroughly reported through the required tools. Though not necessarily specific to PPW-PLT or BCOR, trauma-informed care is important across programs addressing SUD and should be measured to ensure that it is implemented and determine the success of that implementation. Importantly, screening for past trauma should be designed to reduce acute distress among clients (Legerski and Bunnell, 2010), and trauma-specific services should be provided or linked to wherever possible.

Recommendation 3-1: The Substance Abuse and Mental Health Services Administration (SAMHSA) should support grantees in collecting more granular information about history of exposure to traumatic events and history of posttraumatic stress disorder (PTSD) diagnosis in the individuals served by the grants. These data should be used by grantees to better understand and treat beneficiaries of the grant and interpret the success of their programs and by SAMHSA to tailor future grant funding involving those with a history of exposure to traumatic events and history of PTSD diagnosis.

The CSAT GPRA tool allows grantees to report which services they plan to and actually deliver to patients. Methadone is listed as a possible service, though it is not clear whether this is to treat pain or SUD (or both). Buprenorphine and naltrexone are not included on this list, despite the evidence for their effectiveness (NASEM, 2019). In addition, while detoxification is listed as a service in the GPRA tool, there is no provision regarding the clinical protocol. Importantly, it has been shown that rapid detoxification methods without engagement in OUD treatment can place patients at risk for further harm through increased risk of overdose (Carroll et al., 2018; SAMHSA, 2016).

Recommendation 3-2: The Substance Abuse and Mental Health Services Administration should amend data-collection and reporting tools to include a more diverse set of evidence-based treatment options for opioid use disorder (OUD), including medications for OUD.⁷

For patients with co-occurring SUD and another behavioral health diagnosis or infectious disease due to SUD, integrated services have been

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⁷ The committee notes that in the final stages of preparing this report, the GPRA tool underwent an update. Now, the revised tool includes a question specifically about medications for OUD, including methadone, buprenorphine, and naltrexone.

shown to be effective with certain populations and in certain contexts (Amaro et al., 2007a,b; McCauley et al., 2012; NASEM, 2020). To deliver integrated services, patients must receive a valid diagnostic assessment of behavioral health and infectious disease, a treatment plan must be developed to address each of these, and interventions must be delivered in an integrated way (that is, providers must understand the connection between these connected disorders and diseases and use evidence-based approaches to simultaneously address them, including testing, assessment, and treatment). SAMHSA and other organizations have developed a number of tools to assess integration (AHRQ, 2013; Heath et al., 2013; SAMHSA, 2016).

Recommendation 3-3: The Substance Abuse and Mental Health Services Administration should implement measures for grantees to report whether and how patients are treated in an integrated manner and how the targeted service systems have progressed in becoming more integrated.

Given the focus of the PPW-PLT and BCOR grants on RSS, a more targeted set of questions about the experience of recovery for clients may be of additional use to grantees in conjunction with the CSAT GPRA tool. For instance, the Assessment of Recovery Capital (ARC) (Groshkova et al., 2013), the Brief ARC (Vilsaint et al., 2017), or the Substance Use Recovery Evaluator (Neale et al., 2016) may inform SAMHSA and individual grantees about clients’ resilience and buffering strategies against the stress of substance use recovery. SAMHSA can use these data to elucidate best practices across programs and inform future grant program requirements.

Recommendation 3-4: The Substance Abuse and Mental Health Services Administration should implement a validated and psychometrically sound tool for assessing recovery among clients of its grant programs, as the Center for Substance Abuse Treatment Government Performance Results and Modernization Act tool does not elicit adequate data on the process of recovery.

The CSAT GPRA tool⁸ does not include an explicit mention of overdose events, either intentional or unintentional, of fentanyl, or of combination use of opioids and benzodiazepines, even though fentanyl and its analogues are responsible for more overdose deaths in the United

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⁸ See https://www.samhsa.gov/sites/default/files/GPRA/csat_gpra_client_outcome_measures_tool_2017.pdf (accessed April 21, 2020).

States than any other drug (NIDA, 2020) and combining benzodiazepines with opioids increases the risk of overdose (Jones et al., 2012). SAMHSA grantees may benefit from having specific information on their clients regarding overdose events and high-risk drug use, and this information may be useful to SAMHSA for developing a complete picture of opioid use among grant beneficiaries.

Recommendation 3-5: The Substance Abuse and Mental Health Services Administration should include measurements about unintentional and intentional overdose events in its grant reporting tools (e.g., number of events in a given period, outcome of overdose events, first or non-first overdose event), as well as information about fentanyl and concurrent use of opioids and benzodiazepines.

Measurement Effectiveness

The CSAT GPRA questions assessing past 30-day use of drugs and alcohol may be limited because they provide a small window for assessing substance use and do not account for limited opportunities for use while in a restricted environment during the measurement period. For example, days in restriction environments (e.g., inpatient detoxification, residential treatment programs, correctional facilities or inpatient hospitalization) during the measurement period would reduce days of opportunity to use that could erroneously be attributed to treatment. The TimeLine Followback Questionnaire (Robinson et al., 2014) has been validated to assess substance use and other critical events (e.g., days in restricted environments) for longer measurement periods. Furthermore, because SUDs are chronic and relapsing disorders, other indicators of substance use, such as abstention, lapse, and relapse (Gossop et al., 2002; Robinson et al., 2014), could provide a clearer picture of client behavior and assist grantees in improving their services. When administering such tools, it is important to providers remain nonjudgmental about substance use (SAMHSA, 2018). To that end, metrics such as the Harm Reduction Acceptability Scale (Goddard, 2003) could be used to capture staff and provider attitudes about harm reduction.

Recommendation 3-6: The Substance Abuse and Mental Health Services Administration (SAMHSA) should use or develop additional data-collection tools to measure alcohol and drug use in more realistic ways than past 30-day abstention and frequency of use, which do not necessarily capture a clear picture of drug use behavior. Additionally, SAMHSA should encourage grantees to adopt a harm-reduction

approach when interacting with clients, emphasizing that relapse is common and not a signal of personal failure.

Several measures in the CSAT GPRA tool that grantees are required to collect and report may be confusing or are worded such that clients may feel ashamed or alienated from service providers. For instance, questions about whether emotional problems are caused or not caused by substance use may be of limited reliability, as they are contingent on individuals having a clear sense of cause and effect for intertwined psychological phenomena. Different clients may answer these questions differently. Second, several measures are framed such that patients may feel blamed for answering a particular way. For example, a question asks about how many children a client has and for how many they have lost custody; an alternative framing would be to focus on the number of children still living with the client rather than the number for which they have lost parental rights. Third, questions about income may be too vague to provide useful information about a client’s day-to-day living (e.g., do they have enough money for three regular meals per day, housing/rent, heat, clothing, car payments, insurance payments, or medical care for themselves and children under their care). Finally, questions about sexual contacts may be of limited use if not framed sensitively. All such questions should be tested for reliability, particularly with respect to framing effects.

Recommendation 3-7: The Substance Abuse and Mental Health Services Administration should use or develop self-report measures for its grant programs that minimize confusion and risk of alienating patients and clients. This is especially important when asking about sensitive topics, such as substance use, child custody, income, and sexual behavior.

Social Determinants of Health

People who have stable housing are more likely to have success with treatment and stay in recovery longer (Padgett et al., 2011). In the CSAT GPRA tool, clients are asked about their living arrangements and satisfaction with living space. However, there are no questions about safety in their current living situation. Unsafe living arrangements may layer additional trauma on individuals during the recovery process.

Recommendation 3-8: The Substance Abuse and Mental Health Services Administration should incorporate measures of living arrangement safety and perceptions of safety in data-collection tools.

Both the PPW-PLT and the BCOR grant programs have required activities related to developing socio-emotional skills or vocational training. While the CSAT GPRA tool has questions related to employment, it does not measure whether beneficiaries have received training on job readiness. Notably, one current BCOR grantee has instituted a goal to have participants complete 60 hours of skills training in a coffee shop or thrift shop.

Recommendation 3-9: The Substance Abuse and Mental Health Services Administration should support grantees in providing and measuring the success of activities related to job skills and readiness in the Building Communities of Recovery and State Pilot Grant Program for Treatment for Pregnant and Postpartum Women programs.

Systems-Level Change

A key challenge to meeting the SAMHSA grants’ program objectives is assessing the particular factors that promote or inhibit program success. SUD treatment programs vary greatly in length and components; use and fidelity of evidence-based methods; staff training, supervision, and skills; agency characteristics; stability and resources; and client characteristics. Each factor can contribute to client outcomes and disparities in care. To the extent possible, it is important to capture such factors in SAMHSA’s evaluation of its grant programs. For instance, Guerrero and colleagues have shown that agency-level factors are key in SUD treatment success and addressing racial/ethnic inequities in quality of treatment (Guerrero et al., 2013, 2016, 2017a,b).

Recommendation 3-10: The Substance Abuse and Mental Health Services Administration should collect additional program-level data in order to better describe and understand the strengths and needs of funded programs and to determine the evidence-based factors that lead to improved outcomes and reduced disparities for diverse beneficiaries of the Building Communities of Recovery and State Pilot Grant Program for Treatment for Pregnant and Postpartum Women grant programs.

Because BCOR and PPW-PLT focus on building community capacity to support treatment and recovery, there are several important community- and system-level outcomes and metrics that are not currently captured through the GPRA reporting tool or the PPW-PLT program-specific questions. First, with respect to building infrastructure and connections between systems, services, and providers, there is a need to determine

whether the grant program activities have provided stakeholders with new knowledge and changed their day-to-day practices. Additionally, it is important to know whether infrastructure activities have reduced bias and stigma in the community, additional relationships and connections have been made beyond the direct activities of the grantee, state and local policy makers have been briefed on the grantee’s activities, changes have been made in local or state policy, changes have been made in reimbursement or payment arrangements for comprehensive care delivery, or new local or state-funded initiatives have begun based on the activities of grantees. These infrastructural and policy connections and activities may be crucial for sustaining the BCOR and PPW-PLT activities when federal funding ends. Of note, one current BCOR grantee uses a third-party evaluator to track several system-level metrics, including community change, media coverage, additional resources generated, and organizational improvement.

Recommendation 3-11: The Substance Abuse and Mental Health Services Administration should implement additional measurements to assess the system-level change that grantees are making using the Building Communities of Recovery and State Pilot Grant Program for Treatment for Pregnant and Postpartum Women grant funding. This could include surveys of stakeholders impacted by the grant or use of administrative data to determine changes made at the local and state levels in response to grantee activities.

BCOR Recommendations

BCOR grantees are required to use funds to develop and expand RSS, including peer RSS. However, the CSAT GPRA tool does not contain evaluation metrics for specifically assessing how peer recovery coaches, mentors, or support specialists are trained, how they are deemed eligible and certified, how they are integrated into the community, and how they impact the recovery journey of their clients.

Recommendation 3-12: The Substance Abuse and Mental Health Services Administration should support grantees in measuring and reporting how peer recovery services have impacted the overall recovery process for clients served by the Building Communities of Recovery grant.

PPW-PLT Recommendations

There are several additional metrics that could help SAMHSA assess the success of the PPW-PLT grant program.