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Facilitators and barriers to collaboration between drug courts and community-based medication for opioid use disorder providers

Published:January 12, 2023DOI:https://doi.org/10.1016/j.josat.2022.208950

      Highlights

      • Collaborations between drug courts and providers may enhance access to MOUD.
      • Facilitators include comprehensive services, jail referral, effective communication.
      • Logistical limitations ad lack of confidence in providers are perceived as barriers.
      • To enhance collaboration, implementation should address unique drug court features.

      Abstract

      Introduction

      Access to medications for opioid use disorder (MOUD) is limited for individuals in drug courts – programs that leverage sanctions for mandatory substance use treatment. Drug courts rely on community agencies to provide MOUD. However, relationships with MOUD agencies, which impact access to treatment, are understudied. We examined barriers and facilitators from drug court staffs' perspectives to understand how to enhance collaborations with MOUD providers.

      Methods

      Drug court staff (n = 21) from seven courts participated in semi-structured interviews about their experience in collaborating with MOUD providers. Interviews were informed by the Consolidated Framework for Implementation Research. Inductive (theory-based) and deductive (ground-up) approaches were used for analyses.

      Results

      Facilitator and barrier themes centered around the needs and resources of drug court participants, external policies such MOUD access in jails, networking with external agencies, and beliefs about MOUD providers. Drug court staff preferred working with agencies that offered MOUD alongside comprehensive services. Drug courts benefited when jails offered MOUD in-house and facilitated community referrals. Existing relationships with providers and responsive communication eased referrals and served to educate the courts about MOUD. Barriers included logistical limitations (limited hours, few methadone providers) and inadequate communication patterns between providers and drug court staff. A lack of confidence in providers' prescribing practices and concerns around perceived overmedication of participants impacted referrals, interagency collaboration, and further burdened the participants.

      Conclusions

      Collaboration between drug courts and MOUD providers was driven by patient needs, external policies, communication patterns, and perceptions. Interventions to increase access MOUD for drug court participants will need to incorporate collaboration strategies while considering the unique features of drug courts.

      Keywords

      1. Introduction

      Individuals with legal involvement are at high risk of death from opioid overdose (
      • Binswanger I.A.
      • Stern M.F.
      • Deyo R.A.
      • Heagerty P.J.
      • Cheadle A.
      • Elmore J.G.
      • Koepsell T.D.
      Release from prison—A high risk of death for former inmates.
      ;
      • Binswanger I.A.
      • Nguyen A.P.
      • Morenoff J.D.
      • Xu S.
      • Harding D.J.
      The association of criminal justice supervision setting with overdose mortality: A longitudinal cohort study.
      ;
      • Hacker K.
      • Jones L.D.
      • Brink L.
      • Wilson A.
      • Cherna M.
      • Dalton E.
      • Hulsey E.G.
      Linking opioid-overdose data to human services and criminal justice data: Opportunities for intervention.
      ;
      • Pizzicato L.N.
      • Drake R.
      • Domer-Shank R.
      • Johnson C.C.
      • Viner K.M.
      Beyond the walls: Risk factors for overdose mortality following release from the Philadelphia Department of Prisons.
      ). Systemic barriers in criminal legal settings exist that limit access to medications for opioid use disorder (MOUD) – the gold standard treatment for OUD (
      • Friedmann P.D.
      • Hoskinson Jr., R.
      • Gordon M.
      • Schwartz R.
      • Kinlock T.
      • Knight K.
      • Sacks S.
      Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): Availability, barriers, and intentions.
      ;
      • Gordon M.S.
      • Kinlock T.W.
      • Miller P.M.
      Medication-assisted treatment research with criminal justice populations: Challenges of implementation.
      ;
      • Kennedy-Hendricks A.
      • Bandara S.
      • Merritt S.
      • Barry C.L.
      • Saloner B.
      Structural and organizational factors shaping access to medication treatment for opioid use disorder in community supervision.
      ). MOUD includes three types of pharmacotherapies: methadone (opioid agonist), buprenorphine (partial opioid agonist), and naltrexone (opioid antagonist). Methadone and buprenorphine reduce overdose deaths and increase the time to relapse for individuals with legal involvement (
      • Lee J.D.
      • Nunes Jr., E.V.
      • Novo P.
      • Bachrach K.
      • Bailey G.L.
      • Bhatt S.
      • Hodgkins C.C.
      Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X: BOT): A multicentre, open-label, randomised controlled trial.
      ;
      • Wright N.M.
      • Sheard L.
      • Adams C.E.
      • Rushforth B.J.
      • Harrison W.
      • Bound N.
      • Tompkins C.N.
      Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): A randomised controlled trial.
      ), and buprenorphine has been shown to reduce recidivism (
      • Evans E.A.
      • Wilson D.
      • Friedmann P.D.
      Recidivism and mortality after in-jail buprenorphine treatment for opioid use disorder.
      ).
      Drug courts can be both diversionary and sentencing programs, which leverage legal sanctions in exchange for mandatory and court-monitored engagement in substance use treatment (
      National Association of Drug Court Professionals
      Adult drug court best practice standards.
      ). As of 2021, over 3500 drug court programs existed nationwide (). The type of substance that participants struggle with in drug courts varies regionally, but programs observed that many of their participants are diagnosed with OUD (
      • Gallagher J.R.
      • Wahler E.A.
      • Lefebvre E.
      • Paiano T.
      • Carlton J.
      • Woodward Miller J.
      Improving graduation rates in drug court through employment and schooling opportunities and medication-assisted treatment (MAT).
      ;
      • Marlowe D.B.
      • Hardin C.D.
      • Fox C.L.
      Painting the current picture: A national report on drug courts and other problem-solving courts in the United States.
      ;
      • Rodriguez-Monguio R.
      • Montgomery B.
      • Drawbridge D.
      • Packer I.
      • Vincent G.M.
      Substance use treatment services utilization and outcomes among probationers in drug courts compared to a matched cohort of probationers in traditional courts.
      ). A recent study of 849 drug courts found that 86 % of the courts are willing to refer individuals to receive MOUD during program participation. The commonly offered medication treatment was naltrexone (56 %), followed by buprenorphine (50 %) and methadone (36 %). Yet, only 14 % of drug court participants with OUD actually received MOUD (
      • Farago F.
      • Blue T.R.
      • Smith L.R.
      • Witte J.C.
      • Gordon M.
      • Taxman F.S.
      Medication-assisted treatment in problem-solving courts: A national survey of state and local court coordinators.
      ). Despite the vast and compelling evidence of the safety and effectiveness of MOUD, utilization of these medications in legal settings remains low, and implementation challenges remain (
      • Marlowe D.B.
      • Theiss D.S.
      • Ostlie E.M.
      • Carnevale J.
      Drug court utilization of medications for opioid use disorder in high opioid mortality communities.
      ).
      Access to and use of MOUD remains suboptimal for drug court participants (
      • Andraka-Christou B.
      • Nguyen T.
      • Bradford D.W.
      • Simon K.
      Assessing the impact of drug courts on provider-directed marketing efforts by manufactures of medications for the treatment of opioid use disorder.
      ;
      • Elkington K.S.
      • Nunes E.
      • Schachar A.
      • Ryan M.E.
      • Garcia A.
      • Van DeVelde K.
      • Tross S.
      Stepped-wedge randomized controlled trial of a novel opioid court to improve identification of need and linkage to medications for opioid use disorder treatment for court-involved adults.
      ;
      • Marlowe D.B.
      • Theiss D.S.
      • Ostlie E.M.
      • Carnevale J.
      Drug court utilization of medications for opioid use disorder in high opioid mortality communities.
      ;
      • Matusow H.
      • Rosenblum A.
      • Fong C.
      Online medication assisted treatment education for court professionals: Need, opportunities and challenges.
      ). Unwarranted obstacles in MOUD provision and implementation include substantial delays in starting medication treatment, stigmatizing attitudes of staff members and clients alike, and blanket prohibitions of certain medications (
      • Marlowe D.B.
      • Theiss D.S.
      • Ostlie E.M.
      • Carnevale J.
      Drug court utilization of medications for opioid use disorder in high opioid mortality communities.
      ). Notably, however, many drug court staff in this study also reported that they were unaware of barriers, despite limited use of medications, suggestion potential lack of understanding about reality of medication access. Commonly, barriers to MOUD in court settings stem partly from the contextual nature of drug courts, whereby the courts monitor receipt of treatment but typically do not directly provide clinical services. Drug courts usually obtain clinical treatment services by linking participants with collaborating clinical agencies in their community (
      • Taxman F.S.
      • Bouffard J.
      Treatment inside the drug treatment court: The who, what, where, and how of treatment services.
      ). The courts lack funding to pay for clinical services and are limited to the types of locally available treatment services. This “referral and brokerage” model makes drug courts' provision of MOUD dependent on their community partners, and the clinical providers' receptivity and use of MOUD (
      • Farago F.
      • Blue T.R.
      • Smith L.R.
      • Witte J.C.
      • Gordon M.
      • Taxman F.S.
      Medication-assisted treatment in problem-solving courts: A national survey of state and local court coordinators.
      ;
      • Taxman F.S.
      • Bouffard J.
      Treatment inside the drug treatment court: The who, what, where, and how of treatment services.
      ).
      As a result, local treatment agencies, some of which may favor abstinence-based approaches over MOUD, influence drug court personnel's acceptance of MOUD (
      • Andraka-Christou B.
      • Nguyen T.
      • Bradford D.W.
      • Simon K.
      Assessing the impact of drug courts on provider-directed marketing efforts by manufactures of medications for the treatment of opioid use disorder.
      ). Unsurprisingly, strong inter-organizational relationships between drug courts and providers are the best predictors of the availability of specialized treatment services such as MOUD for drug court participants (
      • Taxman F.S.
      • Kitsantas P.
      Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis.
      ), as well as the availability of providers in a community (
      • Farago F.
      • Blue T.R.
      • Smith L.R.
      • Witte J.C.
      • Gordon M.
      • Taxman F.S.
      Medication-assisted treatment in problem-solving courts: A national survey of state and local court coordinators.
      ). Typically, however, relationships between drug court staff and treatment providers have been described by providers as inadequate (
      • Csete J.
      • Catania H.
      Methadone treatment providers'views of drug court policy and practice: A case study of New York State.
      ). Moreover, perspectives from drug court staff about their relationships with MOUD treatment agencies are lacking.
      We seek to address the existing knowledge gap in the perceived barriers and facilitators to accessing and retaining drug court participants in MOUD treatment. To our knowledge, this is the first theoretically based investigation of drug court staff focused on contextual factors around collaboration with treatment providers. This information is critical to developing strategies to improve relationships between drug courts and MOUD providers and implementing evidence-based approaches to increasing access to gold-standard treatment for individuals at high risk of overdose.

      2. Methods

      2.1 Participants

      Participants were staff (n = 21) from seven drug courts in one northeastern US state. Eligibility criteria included being age 18 or older, staff at a drug court site enrolled in the study, and English speaking. Drug court teams typically included a judge, probation officer, prosecutor, defense attorney, clinician, and/or case manager. Generally, three staff were enrolled per site. All participants provided informed consent before study enrollment.

      2.2 Procedures

      Seven drug courts were recruited through collaboration with the state trial court executive office. A senior administrator emailed drug court judges about the study, and the study PI followed up to inquire about their interest. Once a judge expressed interest in having their drug court (i.e., site) participate, they were asked to participate in the study interview and identify other key staff engaged in the MOUD referral and management. The PI subsequently reached out to identified staff to inquire about their interest in study participation. All participants provided informed consent prior to engaging in the study. All study data were collected between March 2021 and June 2021. Participants did not receive stipends due to regulations by the trial court.
      The University of Massachusetts Chan Medical School Institutional Review Board approved all research materials and procedures.

      2.3 Data collection

      Participants completed a one-hour interview by zoom or phone and a brief demographic form. The study PI (a clinical psychologist) conducted all interviews using a semi-structured interview guide grounded in the CFIR framework (
      • Damschroder L.J.
      • Aron D.C.
      • Keith R.E.
      • Kirsh S.R.
      • Alexander J.A.
      • Lowery J.C.
      Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
      ;
      • Fernandez M.E.
      • Walker T.J.
      • Weiner B.J.
      • Calo W.A.
      • Liang S.
      • Risendal B.
      • Kegler M.C.
      Developing measures to assess constructs from the inner setting domain of the consolidated framework for implementation research.
      ) and prior research (
      • Kennedy-Hendricks A.
      • Bandara S.
      • Merritt S.
      • Barry C.L.
      • Saloner B.
      Structural and organizational factors shaping access to medication treatment for opioid use disorder in community supervision.
      ;
      • Matusow H.
      • Dickman S.L.
      • Rich J.D.
      • Fong C.
      • Dumont D.M.
      • Hardin C.
      • Rosenblum A.
      Medication assisted treatment in US drug courts: Results from a nationwide survey of availability, barriers and attitudes.
      ). CFIR was used to develop the interview because this framework has previously been shown to identify implementation barriers and facilitators of substance use treatment programs in legal and community settings (
      • Damschroder L.J.
      • Hagedorn H.J.
      A guiding framework and approach for implementation research in substance use disorders treatment.
      ;
      • Louie E.
      • Barrett E.L.
      • Baillie A.
      • Haber P.
      • Morley K.C.
      A systematic review of evidence-based practice implementation in drug and alcohol settings: Applying the consolidated framework for implementation research framework.
      ). CFIR constructs guided specific inquiries around the outer setting (needs and resources, networking with other agencies, and external policies), inner setting (structural characteristics, communications, access to information), and individual characteristics (beliefs about MOUD). More specifically the interview targeted: 1) access to providers, 2) collaborations with providers, 3) referral and treatment process, 4) barriers, facilitators, and recommendations for change, and 5) perceptions about MOUD.

      2.4 Data analysis and framework

      Audio recordings were transcribed verbatim, redacted for identifying information and double-coded by EP and AKB. The sample size (n = 21) was based on data saturation. Coding and analyses used deductive (CFIR based) and inductive (ground-up) approaches. For inductive analyses, EP and AKB reviewed three interview transcripts to identify preliminary themes and developed codes that corresponded to those themes. Inductive codes were combined with deductive, a priori codes from the CFIR guided interview questions. The initial codebook was refined using the constant comparative methods, ultimately resulting in 34 codes and subcodes. EP and AKB individually coded each transcript and subsequently reviewed and resolved discrepancies. Using the grounded theory approach (
      • Strauss A.
      • Corbin J.M.
      Grounded theory in practice.
      ), we iteratively refined thematic schemes that emerged from the codes until the fewest number of categories was identified. Dedoose Version 9.0 (
      • Dedoose
      Web application for managing, analyzing, and presenting qualitative and mixed method research data. In (Version 9.0.17).
      ) was used to enter and organize data.
      We reviewed three principal codes for this manuscript: relationships with MOUD providers, barriers and facilitators to collaboration, and barriers and facilitators to treatment. Preliminary findings were presented to all participating courts to assure that they were reflective of their experiences. Representative quotes were used to illustrate examples with colloquialisms and utterances removed. See Appendix A for Consolidated Criteria for Reporting Qualitative Research.

      3. Results

      Facilitator and barrier themes were centered around CFIR constructs of needs and resources of drug court participants (importance of comprehensive services, logistical limitations), external policies (MOUD in jails), networking with external agencies (existing relationships, problematic communication), and beliefs about MOUD agencies (lack of confidence in prescribing practices, perceived overmedication).

      3.1 Facilitators

      3.1.1 Importance of comprehensive service agencies

      Drug court staff repeatedly described their preference for working with large community providers that could address the need of their participants for addiction and co-occurring conditions. They sought to work with agencies that provided MOUD alongside mental health, primary care, dental, and specialty services. Comprehensive service agencies were usually community health centers or MOUD clinics within hospitals, as opposed to agencies that only provided MOUD or were operated by private practitioners. Large community providers were described as a “one-stop-shop” and made it easier for the staff and participants to track medications and treatment progress and have a single point of contact. Moreover, these agencies often aided with transportation and insurance and employed peer recovery navigators, valued by the interviewees. Drug court staff particularly sought to work with agencies that also provided mental health services given the state-wide shortage of providers:
      I like to go with agencies that offer co-occurring [MOUD treatment services] because waitlists for mental healthcare are so long…We're gonna need it in some capacity, even if it's not for crisis…but just for trauma-informed issues…I like to use an agency that's big enough that they can help out with that (Probation Officer, Site C).

      3.1.2 Provision of MOUD in jails

      Interviews were conducted during a period of systemic change in state practices, with local jails increasing in-jail access to MOUD and connection of individuals released to community MOUD providers. As a result, some of the jails began to do referrals to MOUD, which had previously been done by drug courts, including scheduling community-based evaluations, providing treatment information, and conducting medical testing required for MOUD. Staff explained how helpful it was for jails to evaluate participants for MOUD, offer treatment in jail, and refer them to community providers upon discharge. This MOUD initiation and linkage in jail potentially reduce a drop-off in treatment during a critical transition and expedited the MOUD community transfer.
      [Local jail is] probably the most phenomenal at this because we really do have such a good relationship with them…The coordination of care is simplified given the team of people we have between the courts and the jail…The jail is pivotal in helping us with setting it up because the [methadone] clinic hours are so minimal. (Court coordinator, Site A).

      3.1.3 Established relationships

      Arguably, the most significant facilitator was pre-existing relationships between community providers and the drug court. Having worked with community providers previously, the staff trusted the MOUD agency to provide appropriate treatment and follow-up care. It also simplified the referral process and increased the likelihood of scheduling appointments quickly in agencies with waitlists.
      You need to have those relationships in the community. Because it's so hard to access services in general. But when someone knows who you are…and why you're calling, it just makes it a little easier (Court coordinator, Site A).
      Courts differed by their frequency and type of relationships with MOUD providers. Some intentionally sought to familiarize themselves with community partners, including inviting them to present at drug court hearings or touring their MOUD facilities. Others made MOUD referrals when necessary and, with time, became familiar with those agencies. Existing relationships with MOUD providers also potentially expanded knowledge about treatment and reduced stigma.
      To be honest with you…I [had] a negative feeling towards methadone…Our [Court Coordinator] had a doctor from [MOUD agency] come over…to speak about methadone, and she just explained it more…It was different…I would be more open to [methadone] since she came. I [now] realize that I don't know as much as [I thought]…[that was] my ignorance. (Probation Officer, Site D).

      3.1.4 Provider responsiveness

      Another important facilitator was the responsiveness of MOUD providers to court needs. There are three time points when drug court staff require information from the provider. The first is during referral and includes intake information (date of the appointment and referral documentation) and confirmation of accepted into treatment, what type, how often, and with whom. The second is during required attendance at drug court hearings, which ranges from weekly (at the start of drug court participation) to every couple of months (towards completion of drug court). During these hearings, the staff review reports from MOUD agencies about treatment progress, attendance, and urine toxicology screens. Finally, the court may need information in between check-ins if they believe the participant has relapsed or is doing poorly.
      Interviewees reported variability in how quickly MOUD agencies reply to court requests. Some responded same or the next day; others required repeated prompts by multiple drug court staff. Accessing treatment information quickly and reliably was critical because it was used to determine, in real-time, whether the participant should remain in the community, need a higher level of care, or would be incarcerated. In cases where information was assessed quickly, the courts could made on-the-spot decisions that potentially reduced the likelihood of an individual to be detained. For instance, when an individual relapsed but was known to remain in treatment, the court incorporate providers' clinical feedback and retained the individual in the community. In situations where clinical information could not be obtained quickly or at all, the burden of responsibility might fall on drug court participants.
      I explained [to the] Judge, ‘I've called them four times this week. I left three messages.’ And then the judge will put it back on the client…and say, ‘You need to have your provider get in touch with them.’ If they have providers who won't speak to us, the judge…will [say] ‘You need to find a new provider… you have to have a provider who's going to work with us.’ (Clinician, Site G).

      3.2 Barriers

      3.2.1 Logistical limitations

      Drug court staff spoke about logistical problems they encountered when seeking MOUD services. Some were specific to the location of the court (e.g., resource-rich versus resource-poor areas) and many were around accessing methadone. For instance, staff described how there was only one methadone clinic in their area, leaving few options for their participants. This scarcity was perceived as a “monopoly” on treatment, with the agency having little incentive to work with patients or agencies to improve their services. Others were concerned about the location and triggers for recurrent use:
      If someone's going to get methadone, and they're going to [location], that's not a great area to send anybody…If I had a participant, and that's where they had to go to get methadone, and they used to score there, or they know that they can score there, do I want to send them there? (Judge, Site A).
      Drug court staff described long waitlists to enroll participants into buprenorphine and extended-release naltrexone. Additionally, some programs had burdensome requirements before participants could begin treatment. Some agencies required group or individual therapy to begin or continue MOUD.
      One of the providers here…to see their [MOUD provider], you have to see your therapist X amount of times. You have to be compliant with your therapy. And then they can put the referral in for [MOUD provider]…and then you get on a list. If you're struggling and you're telling your therapist ‘I'm struggling’ and…you have to wait two or three weeks, you may relapse before that. (Probation Officer, Site E).
      Interviewees reported a range of other problems, including difficulties with transportation to and from providers, limited operating hours for MOUD agencies, conflicting schedules between drug court staff and MOUD clinicians, and problems with insurance. While most participants had state-based Medicaid insurance, the type of Medicaid accepted by the MOUD clinics differed (there are different types and plans available). Sometimes, this required participants to change their Medicaid type to be accepted by the agency. Moreover, participants often had to restart their insurance each time they were released from incarceration, adding another impediment to accessing treatment quickly.

      3.2.2 Problematic communication patterns

      Drug court staff detailed two broad categories of communication problems with MOUD providers. The first was around timeliness of communication, echoing what happened when agencies were not responsive (as was described in the facilitator section). One judge (from Site D) explained, “They don't get back to us…I've reached out to them…I can't reach them…I've tried to have people here connected, and it's just not worked out.” Others observed that even when they did receive information, it could be outdated.
      There are a lot of communication barriers. I would say more so with methadone clinics than buprenorphine and naltrexone providers… I might need to call multiple times. They need a release. I send the release. They didn't get it. I have to send it again. (Clinician, Site E).
      The second problem with communication was around the type of information provided. Court staff believed MOUD providers sometimes held back information if the participant was not doing well. Several courts provided examples of participants testing positive on toxicology screens or using other non-opioid drugs and the MOUD provider not sharing that information when requested. Some drug court staff found this puzzling as they wanted to ensure the participant received the necessary treatment but could not do so if they lacked the essential information.
      Our biggest barrier as far as trying to communicate with these programs…it's hard because I don't know the reason why…they're hesitant to provide us more information…We're all in this person's life. You're [MOUD provider] treating them for substance use. We're trying to help them succeed and maintain their recovery…Why not all be on the same page? (Probation Officer, Site F).
      These communication deficits impacted referral decisions, as staff from site G stated:
      There's no reason that [lack of communication about a document] should be a reason…why I'm not referring somewhere. But that is one of the factors. I will be honest with you.
      This could further compound existing logistical problems, such as a limited number of resources in the community. Poor communication sometimes also resulted in the drug court participant (and treatment patient) having to serve as the go-between the drug court and providers. This gap added further obligations on participants who could be overwhelmed with the demands of the program participation and potentially impacted treater-patient relationships.

      3.2.3 Lack of confidence in prescribing practices

      Staff reported concerns around MOUD prescribing practices across all three types of medications. Interviewees' apprehension about providers appeared to stem partly from a lack of knowledge about agency operations. While many drug court staff received formal training in MOUD, they expressed an interest in learning the specifics of what each agency considered in their treatment decision-making. One probation officer (Site D) summed it up, “What questions do [MOUD providers] ask before they prescribe this medication?” A lack of specific procedural knowledge could translate to potentially erroneous beliefs.
      The problem I have with [MOUD] is not with [MOUD]. I'm a strong believer in it. It's the randomness with which some doctors prescribe the medication with no real patient input. A lot of these doctors are not even seeing these patients in person (Judge, Site F).
      Interviewees also expressed concerns that MOUD services were not comprehensive and did not provide adequate behavioral health treatment. One probation officer (Site F) noted, “I personally feel that the counseling in conjunction with methadone and suboxone is very limited and very surfacy.” Others expressed related concerns about extended-release naltrexone.
      With naltrexone… a lot of times there's not a lot of counseling that goes on with it…A lot of [buprenorphine] programs have a group…with it, or they need to check in with a caseworker and same for methadone. But naltrexone, it might just be once a month, get a shot from a nurse and move on…The treatment providers might not have as much information…if there's psychosocial barriers going on or something like that (Clinician, Site E).
      Communication-related difficulties, such as non-responsiveness and provision of incomplete information, further fueled a lack of confidence and potentially decreased collaboration and referrals.

      3.2.4 Perceived overmedication

      Interviewees described what they perceived as some participants on MOUD being overmedicated. They reported that such participants appeared to nod off and had difficulties communicating and attending to court proceedings.
      It's so difficult…we have one client who…right before…court would [go] to the clinic to get his dose…By the time he got to…court, he'd be nodding. And it's like we need to…change your appointment time or whatever. But this is not appropriate to be coming into drug court looking like you…just used heroin (Clinician, Site B)
      The most prominent concern around overmedication was when participants received MOUD with other medications with sedating properties or could be misused (e.g., Gabapentin). Some referred to a “cocktail” of medications, where many participants were prescribed all the same types of medications in addition to MOUD. Clinician (Site G) noted,
      [MOUD] often becomes an issue when they're also prescribed a million other things. And it's…the combination of [psych meds] with the suboxone, you're going to get high.
      The staff described being most concerned when participants received MOUD from one provider and other medications from a different provider, with limited or no communication between the prescribing agencies. The staff perceived themselves as having the “full picture” of what was going on, while the providers having limited information about what medications their patients were on. Multiple interviewees described attempts at sharing information with providers of their concerns about overmedication. However, they reported difficulties accessing and engaging with providers meaningfully and, therefore, unable to fully relate the extent of their concerns.

      4. Discussion

      Our study extends the literature on the collaboration of drug courts with MOUD community treatment providers. The interviews with drug court staff identified multi-level contextual factors that centered around drug court participant needs and resources, external policies, collaboration with MOUD providers, and perceptions about MOUD services. Specifically, drug court staff described the benefits of working with agencies that offered comprehensive clinical and support services and in areas where jails provided and facilitated MOUD services. These findings also reflect the critical time period to prevent overdoses as individuals are most at risk of an overdose immediately following reentry to the community (
      • Binswanger I.A.
      • Nowels C.
      • Corsi K.F.
      • Glanz J.
      • Long J.
      • Booth R.E.
      • Steiner J.F.
      Return to drug use and overdose after release from prison: A qualitative study of risk and protective factors.
      ;
      Massachusetts Department of Public Health
      An Assessment of Fatal and Nonfatal Opioid Overdoses in Massachusetts (2011–2015). August 2017.
      ). Collaboration was further facilitated by existing relationships with providers and sustained with those who were responsive in their communications.
      Barriers included logistical issues such as location and availability of MOUD providers, transportation to and from agencies, insurance requirements, and waitlists. Interviewees described two challenges to communication – one on the poor timeliness of communication and the other on the inadequacy of information relayed to the drug courts. Drug court staff reported lacking confidence in providers, which stemmed partly from a lack of understanding about how providers operated and what drug court staff perceived as inadequate OUD services (i.e., limited psychosocial treatment). These findings expand on quantitative research with specialty courts (which include drug courts) that found court staffs' beliefs about the trustworthiness of providers were associated with perceptions about and the type of MOUD (
      • Ahmed F.Z.
      • Andraka-Christou B.
      • Clark M.
      • Totaram R.
      • Atkins D.N.
      • Del Pozo B.
      Barriers to medications for opioid use disorder in the court system: Provider availability, provider “trustworthiness”, and cost.
      ). We also observed that the lack of confidence in providers further fueled and potentially reinforced by insufficient communication between the court and those providers.
      Our findings align with other research that explored how criminal legal agencies work with MOUD providers. For instance, Kennedy-Hendricks and colleagues described the complexities of limited MOUD services that probation and parole experienced when contracting with MOUD providers (
      • Kennedy-Hendricks A.
      • Bandara S.
      • Merritt S.
      • Barry C.L.
      • Saloner B.
      Structural and organizational factors shaping access to medication treatment for opioid use disorder in community supervision.
      ). They also identified distrust as one inter-organizational relationship feature.
      • Finlay A.K.
      • Morse E.
      • Stimmel M.
      • Taylor E.
      • Timko C.
      • Harris A.H.
      • Binswanger I.A.
      Barriers to medications for opioid use disorder among veterans involved in the legal system: A qualitative study.
      similarly observed that criminal justice professionals working with veterans with OUD wanted mental health and psychosocial treatments alongside MOUD (
      • Finlay A.K.
      • Morse E.
      • Stimmel M.
      • Taylor E.
      • Timko C.
      • Harris A.H.
      • Binswanger I.A.
      Barriers to medications for opioid use disorder among veterans involved in the legal system: A qualitative study.
      ). In the few regions where jails provide MOUD, community agencies have described the benefits of having treatment initiated and facilitated by jail staff (
      • Matsumoto A.
      • Santelices C.
      • Evans E.A.
      • Pivovarova E.
      • Stopka T.J.
      • Ferguson W.J.
      • Friedmann P.D.
      Jail-based reentry programming to support continued treatment with medications for opioid use disorder: Qualitative perspectives and experiences among jail staff in Massachusetts.
      ;
      • Stopka T.J.
      • Rottapel R.E.
      • Ferguson W.J.
      • Pivovarova E.
      • Toro-Mejias L.D.
      • Friedmann P.D.
      • Evans E.A.
      Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers.
      ). Lastly, the critical nature of inter-agency communications and collaborations, and ways of changing them, have been previously identified as important points of intervention to improve relationships between correctional agencies and MOUD providers (
      • Friedmann P.D.
      • Hoskinson Jr., R.
      • Gordon M.
      • Schwartz R.
      • Kinlock T.
      • Knight K.
      • Sacks S.
      Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): Availability, barriers, and intentions.
      ;
      • Friedmann P.D.
      • Ducharme L.J.
      • Welsh W.
      • Frisman L.
      • Knight K.
      • Kinlock T.
      • Gordon M.
      A cluster randomized trial of an organizational linkage intervention for offenders with substance use disorders: Study protocol.
      ).
      Facilitators and barriers identified in this project can be used to implement or develop strategies to improve collaborations between agencies, with the ultimate goal of assuring individuals with OUD have better access to MOUD. Broadly, implementation strategies to enhance partnerships, engagement, and collaboration include building interagency partner capacities, developing structured communication techniques, expanding partnerships building and communication skills, and providing education (
      • Huang K.-Y.
      • Kwon S.C.
      • Cheng S.
      • Kamboukos D.
      • Shelley D.
      • Brotman L.M.
      • Hoagwood K.
      Unpacking partnership, engagement, and collaboration research to inform implementation strategies development: Theoretical frameworks and emerging methodologies.
      ). More specifically, Friedmann and colleagues developed an organizational linkage intervention that combined education with a liaison between community corrections and MOUD providers, resulting in improved intent to refer to MOUD rates (
      • Friedmann P.D.
      • Ducharme L.J.
      • Welsh W.
      • Frisman L.
      • Knight K.
      • Kinlock T.
      • Gordon M.
      A cluster randomized trial of an organizational linkage intervention for offenders with substance use disorders: Study protocol.
      ). Researchers can further adapt Friedmann et al. (2015) organizational linkage strategy for drug courts by adapting Expert Recommendations for Implementing Change, a compilation of implementation strategies to address challenges unique to drug courts (
      • Powell B.J.
      • Waltz T.J.
      • Chinman M.J.
      • Damschroder L.J.
      • Smith J.L.
      • Matthieu M.M.
      • Kirchner J.E.
      A refined compilation of implementation strategies: Results from the expert recommendations for implementing change (ERIC) project.
      ;
      • Waltz T.J.
      • Powell B.J.
      • Fernández M.E.
      • Abadie B.
      • Damschroder L.J.
      Choosing implementation strategies to address contextual barriers: Diversity in recommendations and future directions.
      ).
      Implementation strategies aimed at improving collaborations between these agencies will have to address practical and financial issues. Specifically, drug courts do not have funds to pay MOUD providers, instead, they refer participants for treatment in the community and those agencies must fit them within their already limited census. Moreover, participants in drug courts likely will require more from MOUD providers than those without legal involvement. Establishing relationships with drug courts similarly takes time that cannot be reimbursed by already burdened agencies. As such, establishing collaborative relationships will require consideration of novel reimbursement techniques for MOUD providers and assure that these are mutually beneficial partnerships.
      Our findings should be interpreted in the context of the strengths and limitations of our study.
      We conducted theory-base, semi-structured interviews with staff at seven drug courts about their perceptions and experiences in working with MOUD providers. We observed the critical nature of inter-agency relationships between drug courts and MOUD providers, and how these relationships may impact the referral of and retention of individuals at high risk for overdose in MOUD services. Moreover, we identified that communication patterns and lack of trust may hamper inter-agency relationships, while external policies where other state agencies, such as jails, offer MOUD treatment can facilitate community referrals.
      However, we also conducted our study in one northeastern state with a generally high availability of MOUD resources and changing state-wide policies that support access to MOUD. States with fewer clinical resources and systems that oppose MOUD are likely to have additional barriers and potentially fewer or different facilitators than we observed. Furthermore, our recruitment used a convenience sample. Accordingly, courts with different perspectives may have chosen to not participate. Nevertheless, we enrolled seven courts from geographically diverse regions of the state. We also conducted our research in the middle of the COVID pandemic, which likely changed practices around the provision of treatment. Our recruitment involved a collaboration with an oversight state agency, which may have impacted the types of responses individuals gave. To minimize any concerns, however, we informed participants that the oversight state agency would not have access to raw data, themes would be anonymized, and our conclusions would be independent of them. Finally, 71 % of our participants reported having received formal training on MOUD. Accordingly, their perspectives about barriers and facilitators to collaboration may have differed from drug court staff who lack knowledge and training about MOUD.

      5. Conclusion

      Drug court staff described contextual facilitators and barriers to collaborating with MOUD providers in referring and retaining drug court participants in treatment. These included factors around participant needs and resources, external policies, networking and relationships, and knowledge and beliefs about MOUD agencies. Collaboration and communication emerged as key points for interventions to improve the referral and retention of participants in MOUD services.

      CRediT authorship contribution statement

      Ekaterina Pivovarova: Conceptualization, Methodology, Writing - Original Draft, Investigation, Formal analysis, and Funding acquisition.
      Faye S. Taxman: Conceptualization, Visualization, and Writing - Review & Editing.
      Alexandra K. Boland: Investigation, Formal analysis, and Writing - Review & Editing.
      David Smelson: Conceptualization, Visualization, and Writing - Review & Editing.
      Stephenie C. Lemon: Conceptualization, Visualization, and Writing - Review & Editing.
      Peter D. Friedmann: Conceptualization, Visualization, and Writing - Review & Editing.
      All authors on this manuscript have contributed substantially to the research and authorship of the paper, and have seen and approved the final version of the manuscript being submitted. This article is the authors' original work, has not received prior publication and is not under consideration for publication elsewhere.

      Funding

      This work was supported by the National Institutes of Health/National Institute of Drug Abuse Career Mentored Award to EP (#DA049953).

      Declaration of competing interest

      None of the authors have any conflicts of interest to report. The views expressed in this article are those of these authors only and do not reflect the position or policies of any of the affiliated agencies.

      Acknowledgments

      We thank the individuals who took the time to participate in this study and their willingness to share their experiences and perceptions about working in drug courts and with community-based medication for opioid use disorder treatment providers. We also thank the state office of the trial court that supported this research and assisted with recruitment.

      Appendix A.

      Table A.1Participant demographics (N = 21).
      n (%)
      Role
       Judge7 (33.3 %)
       Probation officer6 (28.6 %)
       Clinician5 (23.8 %)
       Other3 (7.8 %)
      Gender
       Female16 (76.2 %)
       Male5 (23.8 %)
      Years in role
       1 to 3 years7 (33.3 %)
       3 to 5 years3 (14.3 %)
       5 to 10 years8 (38.1 %)
       10 or more3 (14.3 %)
      Race
       White/Caucasian20 (95 %)
       Black/African American1 (4.7 %)
      Ethnicity
       Not Hispanic or Latino21 (100 %)
      Education
       Associates or equivalent1 (4.8 %)
       Bachelor's Degree5 (23.8 %)
       Master's Degree7 (33.3 %)
       JD8 (38.1 %)
      Formal training on medications for opioid use disorder
       Yes15 (71.4 %)
       No6 (28.6 %)
      Appendix ACOREQ (COnsolidated criteria for REporting Qualitative research) Checklist.
      TopicItem no.Guide questions/DescriptionDetails
      Domain 1: research team and reflexivity
      Personal characteristics
       Interviewer/facilitator1Which author/s conducted the interviews or focus group?EP
       Credential2What were the researcher's credentials? E.g., PhD, MDPh.D.
       Occupation3What was their occupation at the time of the study?Clinical psychologist
       Gender4Was the researcher male or female?Female
       Experience and training5What experience or training did the researcher have?10+ years of clinical interviewing in psycho-legal settings.
      Relationship with participants
       Relationship established6Was a relationship established prior to study commencement?Yes, during research recruitment.
       Participant knowledge of the interviewer7What did the participants know about the researcher? e.g., personal goals, reasons for doing the researchParticipants reviewed a consent form which included information about the study background and aims.
       Interviewer characteristics8What characteristics were reported about the interviewer/facilitator? e.g., Bias, assumptions, reasons and interests in the research topicWe report the education, gender, and discipline of the interviewer.
      Domain 2: study design
      Theoretical framework
       Methodological orientation and Theory9What methodological orientation was stated to underpin the study? e.g., grounded theory, discourse analysis, ethnography, phenomenology, content analysisWe used the CFIR framework and past research to develop the semi-structured questionnaire. We used CFIR and grounded theory to develop coding manual, code, and analyze the findings.
      Participant selection
       Sampling10How were participants selected? e.g., purposive, convenience, consecutive, snowballPurposive sampling was used to recruit drug courts and participants to assure knowledge and experience with MOUD
       Method of approach11How were participants approached? e.g. face-to-face, telephone, mail, emailIndividuals were recruited via email and interviews were conducted via teleconference or phone.
       Sample size12How many participants were in the study?Interviews were conducted with 21 drug court staff from seven courts
       Non-participation13How many people refused to participate or dropped out? Reasons?Fourteen courts were contacted for participation. Of those, 50 % chose to enroll in the study. From those courts, all but two DC staff member contacted chose to participate in the interview.
      Setting
       Setting of data collection14Where was the data collected? e.g., home, clinic, workplaceAll interviewees were asked to be in private spaces during study interviews (either home or work offices).
       Presence of nonparticipants15Was anyone else present besides the participants and researchers?No
       Description of sample16What are the important characteristics of the sample? e.g., demographic data, dateInterviews were conducted with staff from seven drug courts in one northeastern state. Data was collected from April to August of 2021.
      Data collection
       Interview guide17Were questions, prompts, guides provided by the authors? Was it pilot tested?The questionnaire was semi-structured and was reviewed by experts in the field prior to starting the research. There were no formal revisions to the questions, however some phrasing changed throughout the study as interviewees provided responses. Sample questions included: Please describe your relationships with MOUD providers. What are some barriers and facilitators that you encountered in referring drug court pariticipants for treatment? What types of MOUD agencies do you work with and why?
       Repeat interviews18Were repeat interviews carried out? If yes, how many?No. One interview was paused due to interviewee obligations and completed the following day.
       Audio/visual recording19Did the research use audio or visual recording to collect the data?Audio recordings.
       Field notes20Were field notes made during and/or after the interview or focus group?Yes, field notes.
       Duration21What was the duration of the interviews or focus group?Interviews lasted approximately 60 min.
       Data saturation22Was data saturation discussed?Yes, interviews were reviewed to assure that data saturation was achieved.
       Transcripts returned23Were transcripts returned to participants for comment and/or correction?Transcripts were not returned to participants, but overall findings were shared with each site (see below). Manuscript draft was shared with the senior staff of the trial court.
      Domain 3: analysis and findings
      Data analysis
       Number of data coders24How many data coders coded the data?Two
       Description of the coding tree25Did authors provide a description of the coding tree?Codes (categorized data extracts from the interview) were refined using open coding and constant comparative methods, resulting in a coding tree ultimately leading to 34 codes.
       Derivation of themes26Were themes identified in advance or derived from the data?Yes, emergent themes (patterns of responses from multiple respondents that may span more than one code) were derived using a data-driven thematic scheme iteratively developed by the analytical team in keeping with grounded theory.
       Software27What software, if applicable, was used to manage the data?Dedoose v9.0 (Los Angeles, CA)
       Participant checking28Did participants provide feedback on the findings?EP presented findings from the study to each of the courts. Drug courts, which included study participants and team members that were asked to participate, reported that the findings reflected their experiences. Manuscript was also shared with senior staff of the trial court.
      Reporting
       Quotations presented29Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g., participant numberEach quotation had an assigned number. To reduce space and assure confidentiality participant numbers were not used in script.
       Data and findings consistent30Was there consistency between the data presented and the findings?Yes
       Clarity of major themes31Were major themes clearly presented in the findings?Yes
       Clarity of minor themes32Is there a description of diverse cases or discussion of minor themes?Yes
      Developed from: The Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups (
      • Tong A.
      • Sainsbury P.
      • Craig J.
      Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups.
      ).

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