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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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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

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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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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: 978-0-309-26569-0
International Standard Book Number-10: 0-309-26569-X
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Copyright 2021 by the National Academy of Sciences. All rights reserved.

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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.

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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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.

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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Image

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.

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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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

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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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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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:

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.

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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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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 grantees for their work, and for providing information to the National Academies for this study.

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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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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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, 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 has increased with the coronavirus disease 2019 (COVID-19) 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—OUD 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

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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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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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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3-1 Summary of the OD Treatment Access and FR-CARA Programs

3-2 Limitations of Evidence Sources Used by the Committee for the OD Treatment Access and FR-CARA Programs

4-1 Limitations of Evidence Sources Used by the Committee

PPW-PLT-1 Intake Versus Follow-Up Statistics (to Assess for Retention Bias)

PPW-PLT-2 Discharge and 6-Month Follow-Up Statistics

PPW-PLT-3a Program Goal: Reduce the Abuse of Alcohol and Other Drugs (Outcomes Sorted by Interview Type)

PPW-PLT-3b Program Goal: Reduce the Misuse of Alcohol and Other Drugs (Outcomes Sorted by Chronological Order of Interviews)

PPW-PLT-3c Additional Outcomes Sorted by Chronological Order of Interviews

PPW-PLT-4 Program Goal: Increase Engagement in Treatment Services

PPW-PLT-5 Program Goal: Increase Retention in the Appropriate Level and Duration of Services

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

PPW-PLT-7 Additional Program Goals

BCOR-1 Intake Versus Follow-Up Statistics (to Assess for Retention Bias)

BCOR-2 Intake, Discharge, and 6-Month Follow-Up Statistics

BCOR-3 Required Activity 1: Support the Development, Expansion, and Enhancement of Community and Statewide Recovery Support Services (RSS)

BCOR-4 Required Activity 1: Support the Development, Expansion, and Enhancement of Statewide Recovery Support Services (RSS), Including Peer Recovery Support Services

BCOR-5 Allowable Activity 1: Build Connections Between Recovery Networks, Between Recovery Community Organizations (RCOs), and with Other Recovery Support Services (RSS)

BCOR-6 Allowable Activity 2: Reduce the Stigma Associated with Drug/Alcohol Addiction

BCOR-7 Allowable Activity 3: Conduct Public Education and Outreach on Issues Relating to Drug/Alcohol Addiction and Recovery

BCOR-8a Reduction in the Abuse of Alcohol and Other Drugs (Outcomes Sorted by Interview Type)

BCOR-8b Reduction in the Abuse of Alcohol and Other Drugs (Outcomes Sorted by Interview Type)

BCOR-9 Additional Outcomes Sorted by Chronological Order of Interviews

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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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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
CSAP Center for Substance Abuse Prevention (SAMHSA Center)
CSAT Center for Substance Abuse Treatment (SAMHSA Center)
DEA Drug Enforcement Administration
DSP-MRT Division of State Programs Management Reporting Tool (CSAP tool)
EBP evidence-based practice
EHR electronic health record
EMR electronic medical record
EMS emergency medical services
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 and Results Act (CSAT reporting tool)
Page xviii Cite
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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HHS Department of Health and Human Services
HIV human immunodeficiency virus
IRB Institutional Review Board
MAT medication-assisted treatment
MIS management information system
MOU memorandum of understanding
MOUD medications for opioid use disorder
NIDA National Institute on Drug Abuse
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
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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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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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