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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

PROGRESS OF FOUR PROGRAMS FROM THE COMPREHENSIVE ADDICTION AND RECOVERY ACT 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/10.17226/26060 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 2021 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. 2021. Progress of four programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. https://doi.org/10.17226/26060. 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 study’s 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 committee’s 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

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 and Clinical Professor, Post Graduate Psych-Mental Health Program, University of Wisconsin–Madison KAREN CROPSEY, Conaster Turner Endowed Professor of Psychiatry, The University of Alabama at Birmingham JOAN DUWVE, Public Health Specialist, Kansas Department of Health and Environment RAHUL GUPTA, Senior Vice President and Chief Medical and Health Officer, March of Dimes DAVID H. GUSTAFSON, Director, Center for Health Enhancement Systems Studies, University of Wisconsin–Madison (resigned August 2020) MARCELA HORVITZ-LENNON, Senior Physician Scientist, RAND Corporation RAYMOND C. LOVE, Professor and Director, Mental Health Program, School of Pharmacy, University of Maryland YNGVILD OLSEN, Medical Director, REACH Health Services, Institutes for Behavior Resources, Inc. SHARON REIF, Professor, Heller School for Social Policy and Management, Brandeis University Study Staff KATHLEEN STRATTON, Study Director ANDREW MERLUZZI, Program Officer (until August 2020) KELLY MCHUGH, Research Associate (from October 2020) MISRAK DABI, Financial Business Partner CRYSTI PARK, Administrative Assistant ROSE MARIE MARTINEZ, Senior Board Director PREPUBLICATION COPY: UNCORRECTED PROOFS v

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: ANDREA ACEVEDO, Tufts University GEORGES C. BENJAMIN, American Public Health Association MOLLY BROWN, DePaul University CHIN HWA (GINA) DAHLEM, University of Michigan School of Nursing BETHANY DIPAULA, University of Maryland School of Pharmacy CORI SHEEDY, Abt Associates SCOTT STEIGER, University of California, San Francisco 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 JOSIAH “JODY” RICH, Brown University and the Miriam Hospital, and JACK C. EBELER, Health Policy Alternatives, Inc. 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 vii

Acknowledgments The committee of this study thanks Dr. David Gustafson for his service in the early phases of this report. The committee also thanks both the Substance Abuse and Mental Health Services Administration and 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 ix

Contents ACRONYMS AND ABBREVIATIONS xv PREFACE xvii SUMMARY S-1 1 INTRODUCTION AND BACKGROUND 1-1 Comprehensive Addiction and Recovery Act, 1-2 Statement of Task and Report Methodology, 1-4 Organization of the Report, 1-6 2 PPW-PLT AND BCOR PROGRAMS 2-1 Introduction, 2-1 PPW-PLT Program Description, 2-1 BCOR Program Description, 2-2 Methodology, 2-5 Government Performance Reports Act (GPRA) Data Reports, 2-5 Grantee Progress Reports, 2-7 Cross-Cutting Data Limitations, 2-8 Findings: PPW-PLT, 2-10 Required Activity 1, 2-10 Required Activity 2, 2-18 Required Activity 3, 2-20 Allowable Activity 1, 2-20 Allowable Activity 2, 2-21 Allowable Activity 3, 2-21 Summary of PPW-PLT Program Progress, 2-21 Findings: BCOR, 2-21 Required Activity, 2-21 Allowable Activity 1, 2-26 Allowable Activity 2, 2-29 Allowable Activity 3, 2-30 Summary of BCOR Program Progress, 2-32 3 OD TREATMENT ACCESS AND FR-CARA PROGRAMS 3-1 Introduction, 3-1 OD Treatment Access Program Description, 3-1 FR-CARA Program Description, 3-1 Methodology, 3-5 Summary Report from the CSAP Division of State Programs Management Reporting Tool (DSP-MRT), 3-5 Report from the OD Treatment Access Reporting Form, 3-7 Cross-Cutting Data Limitations, 3-8 PREPUBLICATION COPY: UNCORRECTED PROOFS xi

Findings: OD Treatment Access, 3-9 Required Activity 1, 3-9 Required Activity 2, 3-10 Required Activity 3, 3-13 Required Activity 4, 3-17 Required Activity 5, 3-19 Allowable Activity 1, 3-20 Allowable Activity 2, 3-20 Allowable Activity 3, 3-21 Summary of OD Treatment Access Program Progress, 3-22 Findings: FR-CARA, 3-22 Required Activity 1, 3-22 Required Activity 2, 3-25 Required Activity 3, 3-26 Required Activity 4, 3-27 Allowable Activity 1, 3-27 Allowable Activity 2, 3-28 Additional Consideration: Sustainability, 3-28 Summary of FR-CARA Program Progress, 3-29 4 CONCLUSIONS AND RECOMMENDATIONS 4-1 Data Limitations, 4-1 A Note on the COVID-19 Pandemic, 4-3 Conclusions, 4-4 Summary of Evidence of Progress, 4-4 The Forthcoming Final Report, 4-6 Assessing Progress and the Effectiveness of Funded Programs, 4-6 Ensuring Cost-Effectiveness in the Federal Government’s Response to the Opioid Epidemic, 4-9 REFERENCES R-1 APPENDIXES A SUPPLEMENTARY PROGRAM INFORMATION A-1 B SUMMARY TABLES OF CSAT GPRA DATA B-1 C SUMMARY OF COMMITTEE RECOMMENDATIONS IN REPORT 1 C-1 D COMMITTEE BIOGRAPHICAL SKETCHES D-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xii

Boxes and Tables BOXES 1-1 Statement of Task, 1-4 2-1 Recovery Support Services, 2-27 3-1 First Responders and Members of Other Key Community Sectors, 3-2 3-2 Connecting Overdose Survivors to Treatment, 3-13 3-3 Examples of Workforce Development, 3-18 3-4 Policy Context: Good Samaritan and Naloxone Access Laws, 3-24 3-5 Additional Material Highlighted in the DSP-MRT for FR-CARA, 3-30 A-1 PPW-PLT Grantees, A-1 A-2 BCOR Grantees, A-2 A-3 CSAT GPRA Reporting Tool, A-3 A-4 OD Treatment Access Grantees, A-4 A-5 FR-CARA Grantees, A-4 A-6 CSAP Division of State Programs Management Reporting Tool, A-6 A-7 OD Treatment Access Reporting Form, A-7 TABLES S-1 Limitations of Evidence Sources Used by the Committee, S-3 S-2 Summary of PPW-PLT and BCOR Programs, S-5 S-3 Summary of OD Treatment Access and FR-CARA Programs, S-8 2-1 Summary of PPW-PLT and BCOR Programs, 2-3 2-2 Limitations of Evidence Sources Used by the Committee for the PPW- PLT and BCOR Programs, 2-8 3-1 Summary of OD Treatment Access and FR-CARA Programs, 3-3 3-2 Limitations of Evidence Sources Used by the Committee for the OD Treatment Access and FR-CARA Programs, 3-8 4-1 Limitations of Evidence Sources Used by the Committee, 4-2 PPW-PLT-1 Intake Versus Follow-Up Statistics (to assess for retention bias), B-1 PPW-PLT-2 Discharge and 6-Month Follow-Up Statistics, B-13 PPW-PLT-3a Program Goal: Reduce the Abuse of Alcohol and Other Drugs (outcomes sorted by interview type), B-14 PPW-PLT-3b Program Goal: Reduce the Misuse of Alcohol and Other Drugs (outcomes sorted by chronological order of interviews), B-16 PPW-PLT-3c Additional Outcomes Sorted by Chronological Order of Interview, B-17 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii

PPW-PLT-4 Program Goal: Increase Engagement in Treatment Services, B-18 PPW-PLT-5 Program Goal: Increase Retention in the Appropriate Level and Duration of Services, B-18 PPW-PLT-6 Program Goal: Increase Access to the Use of Medications Approved by the Food and Drug Administration in Combination with Counseling for the Treatment of Drug Addiction, B-19 PPW-PLT-7 Additional Program Goals, B-20 BCOR-1 Intake Versus Follow-Up Statistics (to assess for retention bias), B-24 BCOR-2 Intake, Discharge, and 6-Month Follow-Up Statistics, B-38 BCOR-3 Required Activity 1: Support the Development, Expansion, and Enhancement of Community and Statewide Recovery Support Services (RSS), B-41 BCOR-4 Required Activity 1: Support the Development, Expansion, and Enhancement of Statewide Recovery Support Services (RSS), Including Peer Recovery Support Services, B-45 BCOR-5 Allowable Activity 1: Build Connections Between Recovery Networks, Between Recovery Community Organizations (RCOs), and with Other Recovery Support Services (RSS), B-46 BCOR-6 Allowable Activity 2: Reduce the Stigma Associated with Drug/Alcohol Addiction, B-47 BCOR-7 Allowable Activity 3: Conduct Public Education and Outreach on Issues Relating to Drug/Alcohol Addiction and Recovery, B-47 BCOR-8a Reduction in the Abuse of Alcohol and Other Drugs (outcomes sorted by interview type), B-48 BCOR-8b Reduction in the Abuse of Alcohol and Other Drugs (outcomes sorted by interview type), B-50 BCOR-9 Additional Outcomes Sorted by Chronological Order of Interviews, B-50 PREPUBLICATION COPY: UNCORRECTED PROOFS xiv

Acronyms and Abbreviations AIDS acquired immunodeficiency syndrome ASAM American Society of Addiction Medicine AUD alcohol use disorder BCOR Building Communities of Recovery (CARA Program) CARA Comprehensive Addiction and Recovery Act CDC Centers for Disease Control and Prevention CHESS Center for Health Enhancement Systems Studies COVID-19 coronavirus disease 2019 CSAP Center for Substance Abuse Prevention (SAMHSA Center) CSAT Center for Substance Abuse Treatment (SAMHSA Center) DATA Drug Addiction Treatment Act DEA Drug Enforcement Administration DOJ Department of Justice DSP-MRT Division of State Programs-Management Reporting Tool (CSAP tool) EBP evidence-based practice ECHO Extension for Community Healthcare Outcomes EHR electronic health record EMR electronic medical record EMS emergency medical services ER emergency room FDA Food and Drug Administration FOA funding opportunity announcement FQHC federally qualified health center FR first responder FR-CARA First Responders (CARA Program) FY fiscal year GAO Government Accountability Office GPRA Government Performance Results and Modernization Act (CSAT reporting tool) HHS Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act HIV human immunodeficiency virus IRB Institutional Review Board MAT medication-assisted treatment MIS management information system MOU memorandum of understanding PREPUBLICATION COPY: UNCORRECTED PROOFS xv

MOUD medications for opioid use disorder NAMI National Alliance on Mental Illness NIDA National Institute on Drug Abuse NIH National Institutes of Health OD overdose OD Treatment Access Improving Access to Overdose Treatment (CARA program) OD Tx ARF summary report from the OD Treatment Access reporting form OUD opioid use disorder PAF public access file PPW pregnant and postpartum women PPW-PLT State Pilot Grant Program for Treatment for PPW (CARA Program) RCO recovery community organization REACH Recovery Enhanced by Access to Comprehensive Healthcare ROSC recovery-oriented systems of care RSS recovery support services SA substance abuse SAMHSA Substance Abuse and Mental Health Services Administration SBIRT SAMHSA Screening, Brief Intervention, and Referral to Treatment SSA State Agency for Substance Abuse SUD substance abuse disorder PREPUBLICATION COPY: UNCORRECTED PROOFS xvi

Preface At a time in our nation’s history when we are dealing with a major public health crisis from a viral pandemic, while also working to address a longer standing public health crisis from overdose and death from opioid use disorder (OUD), we are pleased as a committee to provide some guidance in this, our second of three reports, on specific initiatives funded by Congress through the Substance Abuse and Mental Health Services Administration (SAMHSA), to address the opioid crisis. The programs included in this report address a number of crucial facets of a public health response to the crisis, spanning prevention of overdose and death, treatment of OUD and co-occurring substance use disorder (SUD), and a pilot in the underdeveloped area of supporting pregnant and postpartum women. With some evidence that the incidence of OUD and overdose deaths involving synthetic opioids have increased with the COVID-19 (coronavirus disease 2019) pandemic, it is now perhaps of even greater importance to determine what we can learn from the implementation of these programs. Data to inform policy would be helpful across these areas. As chairs of this effort, we are grateful for the support of the National Academies and our outstanding colleagues on the committee, to “take the journey” to understand the programs, consider what data are available, and comment on “progress.” Progress of the programs is the main theme of this report, and we have two main considerations of progress. The first is whether and how the programs started up and implemented the activities specified by SAMHSA. The second consideration is about the progress made in the collection of data that would be necessary to understand the impact of the programs. The committee considered the meaning and interpretability of the data provided by SAMHSA and the grantees for this report, and how these may or may not set the stage for impact evaluation—the focus of Report 3. What follows is our committee’s effort to describe that progress and the journey of the programs. May it help us get to clear lessons learned for Report 3, and for our efforts to improve the health of the public in a key area of need—opioid use disorder and its consequences. Kenneth B. Wells (Chair) Hortensia Amaro (Vice Chair) Committee on the Review of Specific Programs in the Comprehensive Addiction and Recovery Act PREPUBLICATION COPY: UNCORRECTED PROOFS xvii

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Substance use disorder (SUD) and opioid use disorder are significant public health threats that affect millions of Americans each year. To help address overdose deaths and lack of access to treatment, the Comprehensive Addiction and Recovery Act (CARA) was signed into law on July 22, 2016. CARA is extensive legislation intended to address many facets of the opioid epidemic, including prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal. It authorizes more than $181 million each year in new funding to fight the opioid epidemic and it requires the implementation of programs and services across the United States to address SUD and recovery.

Following the passage of CARA, the Departments of Education, Health and Human Services (HHS), and Labor, along with the 2018 Related Agencies Appropriations Act, included appropriations for a study of the Substance Abuse and Mental Health Services Administration (SAMHSA) components in CARA, to be conducted by the National Academies of Sciences, Engineering, and Medicine. In response to this charge, the National Academies formed an ad hoc committee to review outcomes achieved by four programs funded by SAMHSA through CARA: State Pilot Grant Program for Treatment for Pregnant and Postpartum Women (PPW-PLT), Building Communities of Recovery (BCOR), Improving Access to Overdose Treatment (OD Treatment Access), and First Responders (FR-CARA). The committee's review is designed to result in three reports over 5 years. This report, the second in the series, reviews reported outcomes and metrics to assess progress toward achieving program goals.

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