Research Design

Research Phases

The section below provides a brief overview of the project activities that will occur in each county across the different phases of the project, which include: Formative, Needs Assessment, Targeted Enhancement Support, Roll-out and Monitoring.

Formative Phase The Formative Phase of the project will lend insight into lessons learned and best practices from early implementers of the opioid court model. This will be completed by reviewing a series of expert panel and administrative data to produce a final "Expert Panel Report" deliverable.
Needs Assessment (5 months) The Needs Assessment Phase will lend insight into key areas of focus or for improvement for each county's opioid court. This will include activities such as identifying county opioid court stakeholder group members (the local change team), site kickoff calls, court administrative surveys, follow-up interviews, inter-agency systems mapping, community provider capacity building, and needs assessment, in order to produce a final "Needs Assessment Report" deliverable.
Targeted Enhancement Support (up to 6 months) The Targeted Enhancement Support Phase will serve as the outline for the county's implementation goals, objectives and activities. This will include a 2-day technical assistance workshop, opioid court action plan development, web-based training, and bi-weekly check-ins. The goal of this phase is to produce an opioid court action plan.
Roll-out (18 months) The Roll-out phase will provide support and facilitation for counties in implementing, evaluating, and revising their opioid court action plan as necessary. Activities in this phase include action plan implementation, ongoing facilitation, data collection on court and treatment outcomes, and data feedback reports with facilitation. As this phase progresses, evaluation and continuous improvement of the opioid court action plan will occur.
Monitoring (6-8 months) The Monitoring Phase will provide ongoing evaluation of counties' opioid court action plan implementation, without additional support or facilitation. Opioid court roll out and data collection on court and treatment outcomes will continue, and data feedback reports will be provided to the counties. The purpose of this phase to evaluate the implementation of the opioid court action plan.

Research Design

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This project capitalizes on a unique real-world scale-up of an innovative opioid court model through implementation of Opioid Court REACH to optimize identification of need and enrollment into treatment/medications for opioid use disorder (MOUD) for court-involved individuals with opioid use(OU)/opioid use disorder (OUD). The project employs a stepped-wedge, cluster-randomized hybrid effectiveness-implementation (type 2) design to examine the efficacy of Project Opioid Court REACH.1 The stepped-wedge research design is used to evaluate service delivery interventions because it reconciles the constraints under which policy makers and service managers operate with the need for rigorous scientific evaluation. Given the high risk of overdose for those with OU/OUD in the court system, randomizing sites to a "control" condition was considered unethical. The counties will be randomized, stratified by population density/urbanicity, county opioid overdose and misuse, and court operation (newly established versus planning) to one of 5 waves of Opioid Court REACH at 2-month intervals. In this stepped-wedge design, data gathered during Opioid Court REACH will be compared to data drawn from drug court from defendants in the same county matched on age, gender, opioid use and arrest. Research paper on the stepped-wedge randomized controlled trial design of this study can be found here.

Guiding Frameworks of the Project

Opioid Care Cascade

Recent development of an OUD cascade of care framework, drawn from approaches used to improve the management of chronic health conditions such as HIV and substance use,2,3 has been proposed as a method to detect gaps in care and identifying places for intervention.4 The cascade outlines the steps an individual takes to begin and remain in treatment, starting with screening and identification of the opioid use problem, followed by clinical assessment, referral and linkage to treatment, then to initiation of treatment, which can include MOUD, through to engagement and retention in treatment, with the final step being remission of the opioid use disorder.

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EPIS & SCT This study uses the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, which identifies necessary structures and processes within systems to support implementation of evidence-based practice.5 EPIS comprises four sequential phases of implementation: exploration (determining needs and available programs, during the Needs Assessment Phase of this project); preparation (planning how to integrate the program into an organization, during the Targeted Enhancement Support Phase of this project); implementation with fidelity (during the Roll-Out Phase of this study), and finally sustainment (during the Monitoring Phase of this project). This framework considers the multilevel nature of service systems and addresses outer (e.g. county funding, overdose rates) and inner contexts (e.g. organizational functioning, staff attitudes), allowing for exploration of barriers to implementation and sustainability. This study also uses social cognitive theory (SCT) to explore how proximal/cognitive variables (e.g. staff attitudes and beliefs about opioid court) and environmental factors influence delivery of the opioid court.6

REFERENCES

  1. Curran, Bauer, Mittman, Pyne, & Stetler. (2012). Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50(3), 217-226.
  2. Belenko, et al. (2017) The juvenile justice behavioral health services cascade: a new framework for measuring unmet substance use treatment services needs among adolescent offenders. Journal of Substance Abuse Treatment. 74, 80–9.
  3. Gardner, McLees, Steiner, Del Rio, & Burman. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Disease. 52, 793–800.
  4. Williams, Nunes, Bisaga, et al. (2018). Developing an opioid use disorder treatment cascade: A review of quality measures. Journal of Substance Abuse Treatment. 2018;91:57-68.
  5. Moullin, Dickson, Stadnick, Rabin, & Aarons. (2019). Systematic review of the exploration, preparation, implementation, sustainment (EPIS) framework. Implementation Science, 14(1).
  6. Bandura. (1989) Human agency in social cognitive theory. American Psychologist, 44(9), 1175-1194.