Review of Four CARA Programs and Preparing for Future Evaluations (2023) / Chapter Skim
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; this trend has continued (SAMHSA, 2021) .1 COMPREHENSIVE ADDICTION AND RECOVERY ACT To help address the challenges of overdose deaths and opioid use disorder and to expand access to evidence-based treatment, the Comprehensive Addiction and Recovery Act (CARA; P.L.
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. THE FOUR CARA PROGRAMS Two of the CARA grant programs -- the State Pilot Grant Program for Treatment for Pregnant and Postpartum Women (PPW-PLT)
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. The specific CARA programs are Building Communities of Recovery; State Pilot Grant Program for Treatment for Pregnant and Postpartum Women; First Responder Training; and Improving Access to Overdose Treat ment.
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PPW-PLT Single state 2017 awards: No more than The purpose of this program is to agencies for 3 15% of the "enhance flexibility in the use of funds substance ($1,100,000 federal funding designed to support family-based abuse each) may be allocated services for pregnant and postpartum to data collection, women with a primary diagnosis of a 2018 awards: performance substance use disorder, including opioid 3 (up to measurement, disorders; help state substance abuse $1,100,000 and agencies address the continuum of care, each)
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• Train or develop the workforce to help state staff or community provider employees to identify mental health or substance abuse or provide effective services consistent with the purpose of the grant program. • Develop policy to support needed services system improvements (e.g., rate-setting activities, establishment of standards of care, adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, development/revision of credentialing, licensure, or accreditation requirements)
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. The information in the Awards and Projects column comes from the Individual Grant Awards pages for OD Treatment Access (SAMHSA, 2017f, 2018e)
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• Provide public education on any state ‘Good Samaritan' laws, such as those that permit bystanders to alert emergency responders to an overdose or to administer FDA-approved overdose reversal drugs without fear of civil or criminal penalties." Required Activities • "Make a drug or device approved or cleared under the Federal Food, Drug, and Cosmetic Act for emergency treatment of a known or suspected opioid overdose available to be carried and administered by first responders (FRs) and members of other key community sectors.
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Assessing Effectiveness For the present report, SAMHSA provided similar information to what was provided for the second report for the CSAT programs. The agency supplied the committee with additional detail and free text responses from the CSAP program grantees mandatory reporting.
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The committee suggested in its second report that a strategy to answering the third interpretation of the charge would consist of an analysis of "how, in the future, Congress can specify required evaluation methods and processes to assess program effectiveness and cost-benefit analysis, and how SAMHSA can improve program evaluation capacity and efforts in similar programs," which "would result in more robust evaluation assessment and information for decision makers responsible for guarding the public's health and related expenditure decisions" (NASEM, 2021)
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Grantees in the PPW-PLT program provided outpatient treatment services to pregnant and postpartum women; several grantees intended to expand the availability of these services to rural areas where they were not previously available. Several grantees used CARA funds to enhance their services by engaging peer support workers or by training staff in evidencebased practices and particularly trauma-informed care relevant to the PPW patient population (Henry et al., 2021; Sperlich et al., 2017)
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Given these challenges and that the programs operated in a complex milieu of health care, public health, criminal justice, law enforcement, child welfare, and employer and community programs, and often across broad geographic areas, the committee cannot attribute some reported outcomes specifically to CARA programs. Finally, other considerations such as timing of the evaluation, details of the data sharing agreements between SAMHSA and grantees, and level of SAMHSA support to grantees for evaluation purposes from the outset precluded a rigorous evaluation of program effectiveness.
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CONCLUSION 3: CARA funding supported grantees in enhancing or expanding treatment and recovery support services, as well as naloxone delivery. Grantees facilitated the education and training of community members and professionals about substance use disorder, stigma reduc tion, and overdose reversals.
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Among the common barriers experienced by grantees, several related to communication and management challenges with SAMHSA, including low funding levels, short implementation time frames, delays in budget approval, lack of communication with SAMHSA government program officers, a desire for additional technical assistance, and the administrative burden of mandated reporting tools. Grantees may have benefited from additional technical assistance from SAMHSA with data collection, which also proved to be a challenge for many grantees.
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To obtain information useful for policy making through an effective evaluation requires substantial coordination, support, and data sharing among stakeholders (Congress, the implementing agency, grantees and partners, and the evaluator)
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Additionally, SAMHSA contracted with the National Academies to perform the review of the programs more than 1 year after Funding Opportunity Announcements were issued for the cohorts under study, mandatory reporting tools were selected and in use, and grantees had already 9 Throughout this chapter and report, "program" is used to refer to an overarching federal grant programs (e.g., one of the four CARA programs) , rather than to a project conducted by one of the grantees of those programs.
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To achieve alignment of evaluation expectations with feasibility and resource considerations, Congress should confer with the implementing agency and evaluation experts. To facilitate this process, Congress should provide funding as early as possible to allow for ample time to coordinate with the implementing agency on how to best scope and plan the required assessment activities before grantees begin their implementation process.11 If brought in early, the parties can work together to help tailor data collection and evaluation methodology (e.g., research design, sampling, types of data required and most appropriate means of collecting those data, and analytic approach)
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Having adequate capacity, mission, and culture, as discussed above, enables the implementing agency to support grantees by (a) selecting appropriate data collection systems, (b)
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The reader should not take away from these three reports that the committee believes that grantee efforts were not useful; the committee has highlighted evidence that SAMHSA's grantees have used the CARA funding to stand up and expand activities that were not previously available and that provide value to individuals with SUD, to the professionals working toward addressing the SUD epidemic, and to grantees' communities. These efforts have already served individuals and communities and are likely to promote population health in the long run.
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