Opioid overdose is the leading cause of death among people recently released from incarceration. Recent evidence also shows a rise in stimulant use among justice-involved populations, as well as growing rates of concurrent opioid and stimulant use. Yet, while there is growing research on opioid use disorder (OUD), stimulant use disorder (STUD), and substance use treatment in jails and prisons, studies find that few people who are referred to community substance use treatment actually initiate treatment after release. But, emerging research suggests that therapy for posttraumatic stress disorder (PTSD), a common and deleterious OUD and STUD comorbidity, could profoundly increase the likelihood of engagement with substance use treatment; however, this has not been tested in jails, and acceptable, appropriate, and feasible ways to identify and link people with probable PTSD and OUD/STUD in this setting to treatment are required to be able to examine this possibility. Therefore, this 4-year R33 aims to 1) describe engagement in and examine the implementation outcomes of an innovative approach to identifying and referring people with probable PTSD and OUD/STUD to needed treatment services and 2) the effectiveness and implementation outcomes of two competing models of subsequent trauma-focused therapy initiation timing (i.e., immediate initiation of therapy vs initiation upon community reentry) among people who demonstrate need for OUD/STUD services and who accept referral. To address Aim 1, the investigators will assess the implementation context for and subsequently implement a screening, brief intervention, and referral to treatment model that was adapted to identify and address the substance use and mental health needs of adults with probable PTSD and OUD/STUD in the jail setting (SBIRT-J) in the Pulaski County Regional Detention Facility; the investigators will describe engagement in and examine the implementation outcomes of the SBIRT-J model via a summative evaluation guided by the Consolidated Framework for Implementation Research. Specifically, there will be a survey and interview jail stakeholders (e.g., jail leadership, officers) to understand perceptions of the acceptability, appropriateness, and feasibility of the SBIRT-J model as well as SBIRT-J implementation determinants (i.e., barriers and facilitators), and use administrative data to understand the degree to which SBIRT-J is adopted during active enrollment in the R33 Aim 2 research trial and sustained in the 6 months after enrollment end. Fidelity to the SBIRT-J model will also be monitored and reported. To address Aim 2, the investigators will conduct a patient-randomized Hybrid type I implementation-effectiveness trial in which adults who are identified as having probable PTSD and OUD/STUD through the SBIRT-J model and who consent to participate in the trial are randomly assigned to either immediate initiation of therapy for PTSD in jail or initiation of PTSD therapy upon release. The primary effectiveness outcome will be post-release substance use treatment initiation by 6-months post-release from jail; secondary and exploratory outcomes will include substance use treatment readiness and retention, OUD/STUD severity, PTSD symptoms, victimization, overdose, and additional drug use. Participants in the effectiveness portion of the trial (N = 338; \~50% female) will be enrolled from the largest jail in Arkansas. Jail stakeholders will also be enrolled to provide implementation-related data. The overall goal is to translate research to practice to increase the provision of high-quality care for justice-involved persons with probable PTSD and OUD/STUD. Indeed, this study will be the first trial of a treatment for PTSD in jails as a method for improving OUD/STUD outcomes, providing foundational information on PTSD as a novel intervention target for meeting the needs of a particularly vulnerable population and providing the implementation data to inform rapid scale-up, if effective.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
338
Cognitive Processing Therapy (CPT) is an evidence-based therapy for PTSD that helps people understand how trauma has impacted their life and learn balanced ways to think about the trauma. Participants who choose to pursue CPT will complete worksheets and talk about them with a counselor. CPT will be offered individually; in-person, televideo, and/or phone visits will be acceptable. CPT
Written Exposure Therapy (WET) is an evidence-based therapy for PTSD that helps people face memories of trauma so they become less upsetting over time, which can helps people feel more in control of their emotions and reactions. Participants who choose to pursue WET will write about the traumatic event and then talk with a counselor. WET will be offered individually; in-person, televideo, and/or phone visits will be acceptable.
Pulaski County Regional Detention Facility
Little Rock, Arkansas, United States
University of Arkansas for Medical Sciences
Little Rock, Arkansas, United States
A2 - Substance Use Treatment Initiation
Substance use treatment initiation (binary; presence vs absence) will be assessed via participant self-report and verified via medical chart review when possible.
Time frame: Through study completion, approximately 1 year
A1 - SBIRT-J Acceptability per the Acceptability of Intervention Measure (AIM)
The extent to which SBIRT-J is perceived as satisfactory by stakeholders. Mean scores on the AIM range from 1-5, with higher scores indicating greater intervention acceptability.
Time frame: Immediately following the conclusion of Aim 2 enrollment (one-time survey)
A1 - SBIRT-J Appropriateness per the Intervention Appropriateness Measure (IAM)
The extent to which SBIRT-J is perceived by stakeholders as relevant to and compatible with the setting and population. Mean scores on the IAM range from 1-5, with higher scores indicating greater intervention appropriateness.
Time frame: Immediately following the conclusion of Aim 2 enrollment (one-time survey)
A1 - SBIRT-J Reach
The ratio of people who complete SBIRT-J to the number who are booked in the PCRDF during the study period.
Time frame: Immediately following the conclusion of Aim 2 enrollment
A1 - SBIRT-J Feasibility per the Feasibility of Intervention Measure (FIM)
The extent to which SBIRT-J is perceived by jail stakeholders as useable. Mean scores on the FIM range from 1-5, with higher scores indicating greater intervention feasibility.
Time frame: Immediately following the conclusion of Aim 2 enrollment (one-time survey)
A2 - Retention in Substance Use Treatment
Retention in substance use treatment once initiated will be assessed via participant self-report and verified via medical chart review when possible.
Time frame: Through study completion, approximately 1 year
A2 - Opioid Use Disorder Severity
Opioid use disorder (OUD) severity will be assessed via a DSM-5 checklist of OUD diagnostic criteria; this checklist has a maximum score of 11, with higher scores indicating more severe symptoms and scores of ≥2 indicating symptoms likely to meet criteria for OUD. Scores will be examined as both dichotomous (presence vs. absence) and continuous (total number of symptoms).
Time frame: Through study completion, approximately 1 year
A2 - Stimulant Use Disorder Severity
Stimulant use disorder (STUD) severity will be assessed via a DSM-5 checklist of STUD diagnostic criteria; this checklist has a maximum score of 11, with higher scores indicating more severe symptoms and scores of ≥2 indicating symptoms likely to meet criteria for STUD. Scores will be examined as both dichotomous (presence vs. absence) and continuous (total number of symptoms).
Time frame: Through study completion, approximately 1 year
A2 - Opioid Use
Opioid use will be assessed via participant self-report on the 30-Day Timeline Follow Back Interview and will be examined as both a binary variable and a frequency count representing number of days of use.
Time frame: Through study completion, approximately 1 year
A2 - Stimulant Use
Stimulant use will be assessed via participant self-report on the 30-Day Timeline Follow Back Interview. The total number of days of stimulant use will be calculated and examined as a frequency count.
Time frame: Through study completion, approximately 1 year
A2 - Overall Drug Use Frequency
Assessed by the Timeline Follow Back Interview. Will be examined as a frequency count (number of days used in the previous 30 days).
Time frame: Through study completion, approximately 1 year
A2 - Post-Traumatic Stress Disorder (PTSD) Symptom Severity
Per the PTSD Checklist for DSM-5. Will be a continuous score of 0-80, where lower scores indicate lower PTSD symptoms and thus a better treatment outcome.
Time frame: Through study completion, approximately 1 year
A2 - Drug-Related Crime
Assessed via the Criminal and Legal Activities Form. Will primarily be defined as 1) new arrests for drug charges and 2) new convictions for drug charges and will be examined as both a binary variable (presence or absence of any drug-related crime) and frequency counts (number of new drug charges or convictions).
Time frame: 12 months post-baseline
A2 - Depressive Symptoms
Assessed via the Patient Health Questionnaire-8. Depressive symptoms will be a continuous score of 0-24 where lower scores indicate lower symptom levels and thus a better treatment outcome.
Time frame: Immediately and until 12 months post-baseline
A2 - Perceived Appropriateness of SBIRT-J
Will be assessed with the Intervention Appropriateness Measure.
Time frame: Immediately (baseline-only)
A2 - Perceived Acceptability of SBIRT-J
Will be assessed with the Acceptability of Intervention Measure.
Time frame: Immediately (baseline-only)
A2 - Perceived Appropriateness of Cognitive Processing Therapy (CPT)
Will be assessed with the Intervention Appropriateness Measure.
Time frame: Immediately (baseline-only)
A2 - Perceived Acceptability of Cognitive Processing Therapy (CPT)
Will be assessed with the Acceptability of Intervention Measure.
Time frame: Immediately (baseline-only)
A2 - Perceived Appropriateness of Written Exposure Therapy (WET)
Will be assessed with the Intervention Appropriateness Measure.
Time frame: Immediately (baseline-only)
A2 - Perceived Acceptability of Written Exposure Therapy (WET)
Will be assessed with the Acceptability of Intervention Measure.
Time frame: Immediately (baseline-only)
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