Fostering MAT Use in Justice Populations
Phase: NA
Conditions: Opioid-use Disorder, Recidivism
Sponsor: University of Wisconsin, Madison

1 
 
  
 
 
 
Justice Community Opioid Innovation Network (JCOIN) 
Coordination & Translation Center  
Aim #1 Protocol 
 
Fostering MOUD Use in Justice Populations 
 
 
PIs: Todd Molfenter, Ph.D. 
     Faye Taxman, Ph.D. 
          
 
 
March 2, 2020 
 
NCT# 04363320 
 
 
 
 
 
 
 
 
 

2 
 
 
Principal Investigators:  
  
  
Todd Molfenter, Ph.D.  
University of Wisconsin - Madison  
Industrial Engineering  
1513 University Avenue, ME Bldg. Suite 4103  
Madison, WI 53706  
608-262-1685; todd.molfenter@wisc.edu  
Faye Taxman, Ph.D. 
George Mason University 
4087 University Blvd, Ste 4100 
Fairfax, VA 22030 
703-993-8555; ftaxman@gmu.edu 
 
 
Researchers: 
  
Jee-Seon Kim, Ph.D.  
University of Wisconsin - Madison  
Educational Psychology  
1025 W. Johnson Street, 1057 Educational Sciences  
Madison, WI 53706  
608-262-0741; jeeseonkim@wisc.edu 
  
Nora Jacobson, Ph.D. 
University of Wisconsin-Madison 
Institute for Clinical and Translational Research 
Community Academic Partnerships Program 
608-262-8034; najacobson@wisc.edu 
  
Randy Brown, Ph.D., MD 
Dept of Family Medicine & Community Health 
University of Wisconsin School of Medicine & Public Health 
1100 Delaplaine Ct., Rm 3834 
Madison, WI 53715 
608-263-6558; rtbrown@wisc.edu 
 
Alex Breno, M.A. 
Center for Advancing Correctional Excellence! 
George Mason University  
4087 University Blvd 
Fairfax, VA 22030 
703-993-5222; abreno@gmu.edu 

3 
 
 
Study Coordinator:   
Jessica Vechinski, MSW 
University of Wisconsin-Madison 
Industrial Engineering  
1513 University Avenue, ME Bldg. Suite 4155 
Madison, WI 53706  
608-262-4378; jvechinski@wisc.edu 
 
Sponsor: National Institute on Drug Abuse/Helping End Addiction Long-Term  
  
Protocol Version:  Version 1.0 
   
  
 
 

4 
 
Contents  
1. BACKGROUND  ...................................................................................................................................... 5 
2. STUDY SYNOPSIS ................................................................................................................................... 5 
3. STUDY OBJECTIVES................................................................................................................................ 6 
4. SELECTION OF SUBJECTS ....................................................................................................................... 7 
5. REGISTRATION PROCEDURES ............................................................................................................... 8 
6. STUDY & TREATMENT PLAN ................................................................................................................. 8 
7. POTENTIAL RISKS ................................................................................................................................ 17 
8. MEASUREMENT OF EFFECT ................................................................................................................ 18 
9. STUDY PARAMETERS ........................................................................................................................... 18 
10. STATISTICAL CONSIDERATIONS ........................................................................................................ 19 
11. RECORDS TO BE KEPT........................................................................................................................ 21 
12. ACRONYM LIST .................................................................................................................................. 22 
13. REFERENCES CITE .............................................................................................................................. 23 
 
  
 
 
 
 
 
 
 
 
 
 
 
 

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1. BACKGROUND  
The need for treatment and prevention of overdose is a national priority according to the 
Centers for Disease Control (CDC) which lists expanding access to addiction treatment services 
as an essential component in the response to the opioid overdose epidemic.1 Less than 10% of 
justice-involved individuals are able to access behavioral health services on any given day 
regardless of setting (i.e. jail, probation, etc.),2-5 however the Criminal Justice System (CJS) has 
some constitutional driven needs to provide behavioral health care (i.e., mental health and 
substance use) to the largest concentration of U.S. adults with behavioral health needs. Nearly 
11 million individuals pass through local jails each year,6,7 5 million individuals are on parole or 
probation,8 and 1.5 million are in state and federal prisons.6 Among CJ populations, the rate of 
past-year substance use disorder (SUD) (66%),1,9-19 lifetime opioid use (15%),1 and pain 
medication dependence (11%)1 are dramatically elevated compared to the non-criminal justice 
population, resulting in overdose,12 suicide,20-22 disabilities and physical disorders,23–25 
homelessness,26 and death.27,28   
 
While pharmacotherapy holds great promise, medications are underutilized in SUD treatment, 
both in and out of the CJS. 29,30 Of the three most common medications for opioid use disorders 
(MOUDS)--methadone, injectable naltrexone, and buprenorphine-- all possess evidence that 
they increase retention in treatment, reduce self-reported use of opioids, and reduce criminal 
activity and mortality.3 Approximately 80% of those with opioid use disorders (OUD) do not 
receive appropriate treatment.4,5 Utilization of MOUD among justice populations is even 
lower31 with justice referred patients being one-tenth as likely to receive agonist MOUD as 
other patients.32 Addressing justice system actors’ attitudes is important for expanding use of 
medications33 and for guiding implementation. 
 
The CJS offers an opportune setting to disseminate and implement evidence-based practices 
(EBPs) because of the gap between evidence and practice, potential return on investment in 
order to reduce fatalities, reduced burden on the health and criminal justice (CJ) agencies, and 
improved quality of life. The pressing question is how best to facilitate dissemination, adoption, 
implementation, and sustainment of EBPs for CJ populations. 
 
2. STUDY SYNOPSIS 
The current timeframe from research lab to practice is 17 years, with only 14% of clinicians 
reporting use of evidence-informed knowledge in their clinical practice.34 Complexities of the CJ 
or health systems coupled with interagency features present challenges to the effective 
dissemination, adoption, implementation, and sustainment of evidence-based practices. 
Coaching is a favored implementation strategy, yet coaching dosage and mediums have not 
been adequately tested or assessed in CJ settings. Scaling up in CJS, particularly MOUD 
utilization, presents a challenge given staffing resources available, acceptance of addiction 
treatment, and historical preference for behavioral therapy-based treatment practices that 
often do not include use of MOUD. In this trial, we will test two implementation interventions 
being applied to MOUD dissemination and implementation in justice settings for justice-
involved populations: NIATx Coaching and the Extension for Community Healthcare Outcomes 

6 
 
(ECHO) model. NIATx Coaches provide expertise in MOUD implementation and organizational 
change to help treatment organizations and staff make, sustain, and spread MOUD. The ECHO 
platform focuses only on the provider side by connecting the primary care provider with expert 
MOUD prescribers to promote high-quality MOUD practices. This will be the first trial that 
assesses the comparative effectiveness of these approaches overall, and in justice settings. 
 
The trial will be conducted with a combination of 48 jails and community-based organizations 
that treat individuals with OUDs post-incarceration. Sites will be randomly assigned to one of 
four study arms, with 12 sites in each arm: High-Dose Coaching/ECHO, Low-Dose 
Coaching/ECHO, High-Dose Coaching/No ECHO, and Low-Dose Coaching/No ECHO. The 
intervention period will be over a 12-month span with an additional 12-months for 
sustainability. 
 
3. STUDY OBJECTIVES  
The specific aim of this study is to compare High-Dose NIATx Coaching/ECHO, Low-Dose NIATx 
Coaching/ECHO, High-Dose NIATx Coaching/No ECHO, and Low-Dose NIATx Coaching/No ECHO. 
Impact will be measured using the RE-AIM framework: 
 Reach (primary aim) measured as the percent of eligible justice involved patients who 1) 
are initiated onto any MOUD (buprenorphine, extended-release injectable naltrexone, 
or methadone), and 2) engaged with MOUD use. 
 Effectiveness measured in terms of impact of MOUD involvement on re-arrest rates. 
 Adoption measured as the percent of eligible clinicians in jail and/or community 
providers who use MOUD. 
 Implementation measured by an organizational readiness for MOUD implementation 
over time and intervention fidelity scale (for NIATx and ECHO). 
 Maintenance measured as the likelihood of organizations sustaining provision of MOUD 
utilization (organizational sustainability scores at 12 and 24 months of intervention) and 
we will continue to collect Reach, Effectiveness, and Implementation measures during 
the maintenance phase (Ms 12-24). 
 
Study Coordination  
The UW-Madison Center for Health Enhancement Systems Studies (CHESS) and George Mason 
University Center for Advancing Correctional Excellence! are the coordinating sites for this 
study. George Mason holds the grant award for the larger study this research is embedded in. 
The UW site will oversee all recruitment and study implementation activities which includes:   
• 
developing organizational site-specific recruitment and data collection processes that 
meet study objectives;  
• 
training staff on protocol procedures prior to start of recruitment and continuous 
monitoring to assure compliance with the protocol and human subjects regulation;  

7 
 
• 
communicating with clinic site staff as needed via conference calls to monitor progress, 
inform of protocol changes/distribute new version of protocol, and address 
unanticipated issues or challenges;  
 
• 
manage all study data;  
• 
oversee analysis; and 
• 
oversee publications and presentations. 
  
4. SELECTION OF SUBJECTS  
This study will engage jails and post-incarceration community-based organizations serving 
justice involved persons including correctional and health staff and medical teams at those 
sites/organizations. 
Organizations: Up to twelve (12) jails and community-based organizations from around the 
country, eighteen (18) jails and community-based organizations in Wisconsin, and eighteen (18) 
jails and community-based organizations in Virginia, with a total of forty-eight (48) sites will be 
recruited for this study.    
Participating sites will receive $1,000 in Year 1 and again in Year 2 for participating in the study 
and for submitting organizational and staff data. The funds will be used to pay for study data 
and/or study material.  
Sites to be approached for recruitment will be: sites that have expressed interest in the grant, 
organizational sites that provide post incarceration addiction treatment services, and jails that 
provide addiction treatment services within the jail. Once sites have been identified, they will 
be asked to sign an IRB approved Information Sheet (Memorandum of Understanding) to 
indicate their understanding of the study protocol and willingness to participate in the study.  
Pre-Requisites for Site Participation:  
 Have an interest in embedding or increasing the use of MOUD within their site. 
 Have the funds to pay for medications for the duration of the study (24 months); 
whether it be from grants, insurance or private pay. 
 Sites agree to implement or continue to use at least one medication, although they will 
be encouraged to offer more than one medication. 
 Have leadership support at all levels. 
 Sign a Memorandum of Understanding (MOU) or Information Sheet. 
 Agree to provide data described in the MOU or Information Sheet. 
Executive Sponsor, Change Leader & Team: Each site will be asked to identify an Executive 
Sponsor to represent their respective site. This individual will be in a leadership role such as 
Director, CEO, Sherriff, etc. The Executive Sponsor will be responsible for identifying a ‘Change 
Leader’ or ‘site liaison’ (someone in a management role), willing to coordinate the study 
elements. It is then up to the Executive Sponsor and Change Leader to identify up to 7 staff 
members that will be a part of the ‘Change Team’ in the jail setting. Members of the Change 

8 
 
Team for purposes of community linkage should include CJ staff (jail or probation), health 
provider representative, medical provider/prescriber (i.e. nurse, physician, etc.) to ensure that 
the team has reach to various pertinent audiences. Additional members on the Change Team 
can hold a variety of positions including counselor, nurse, social worker, case manager, etc. 
Change teams will also be present in the post incarceration community-based provider jail SUD 
partner sites and will also include variety of positions including counselor, physician, nurse, 
social worker, case manager, etc. Once participating staff is identified by role in the jail and 
post-incarceration CB provider sites, recruited staff will be emailed invitations to complete 
organizational/staff surveys and/or a phone interview along with a study consent form. Any 
staff member may formally decline to participate during the training portion of the study or any 
time thereafter. 
 
5. REGISTRATION PROCEDURES  
Organizational and Staff Recruitment 
Organizational Surveys: The Executive Sponsor (or their designee) will complete the 
organizational surveys and may be asked to complete a short qualitative phone interview. 
Staff Survey: The staff surveys will be completed by staff that are a part of the Change Team.  
Physician Survey: The Physician Survey will be completed by physicians/prescribers working at 
the sites.  
The Executive Sponsor will not have access to the survey data nor will they receive any data 
feedback or summaries from the surveys. The IRB approved consent form will describe that 
completing the staff or organizational survey infers their consent. For those who do not 
complete the survey, the survey will not be recorded and no record of the person not wanting 
to participate will be made. The consent form will be the first portion of the on-line survey to 
be administered through REDCap. 
All surveys will be accessed through REDCap, a secure web-based platform, licensed by 
University of Wisconsin, that is used for building and managing online databases and surveys.  
 
6. STUDY & TREATMENT PLAN  
Study Design  
The proposed study will implement a cluster randomized block design where staff are nested 
within sites. The community-based provider sites and jails will be grouped into homogeneous 
blocks and then randomly assigned into 2x2 design for each block. The forty-eights sites will be 
assigned to one of four study arms using a matching strategy within the blocks that groups four 
jail-clinic combination together prior to randomization. Each jail and CB treatment provider (or 
clinic) in these combinations will be treated as a site.  For instance, if a jail has two post 
incarceration CB treatment providers (or clinics) in the trial, this will be 3 total sites (of the 48 
sites). Within the matching block of 4 jail-clinic combinations, one jail-clinic combination will be 
randomized to an arm of the study. Twelve sites (that will consist of jails or post incarceration 

9 
 
CB treatment sites) will be assigned to each arm. The number of jails and post-incarceration 
sites per arm are expected to be balanced, with an anticipated 4 jails and 8 post-incarceration 
CB provider sites per arm.  
 
Matching will be based on; a) number of clinic sites the jail will be including in the study (as part 
of the jail-clinic combination), population of the county where the jail is located, and whether 
or not the jail is currently providing MOUD to CJ population, and if so, what type of MOUD. The 
blocking procedure will reduce variability within treatment conditions and yield more precise 
estimates of treatment effects. This strategy will allow for the study team to examine the 
effects of High versus Low-Dose coaching and ECHO on MOUD use rates in large and small 
settings. In the study design, there will be a 12-month implementation period followed by 12 
months to track sustainability. Data will be collected at baseline, 12 months and 24 months. 
 
Intervention 
There will be two “scaling-up practices” used in this study; NIATx Coaching and ECHO Clinical 
Mentoring. The study will look at combination of these two practices to create four 
intervention study arms;  
1) High-Dose Coaching/ECHO,  
2) Low-Dose Coaching/ECHO,  
3) High-Dose Coaching/No ECHO, and  
4) Low-Dose Coaching/No ECHO 
Scaling up Practice #1: NIATx Coaching. NIATx framework provides each participating site with 
a NIATx Coach who is an expert in MOUD implementation and organizational change and will 
help the organization adopt, implement, and increase the use of MOUD. Coaches help the sites 
think through key issues, offer process improvement training, and suggest changes. NIATx 
coaches in the High-Dose and Low-Dose arms will interact with the organization described in 
Figure 1. The High-Dose coaches will conduct an on-site visit with the site Change Team and 
complete 11 monthly one-hour calls (months 2-12 of intervention) following the kick-off 
meeting. Coaches in the Low-Dose arm will hold a one-hour introduction call with the Site 
Change Team and conduct a two-hour NIATx training via webinar and three quarterly, one-hour 
calls at months 4, 8 and 12 with the Change Team following the kick-off meeting. 
 
 
 
 
 
 

10 
 
Figure 1: NIATx Coaching (During 12-month Intervention Period) 
 
 
Step1. Define Aims: Executive sponsor 
briefing on project during an in-person Kick-
off meeting with Study Team & other 
Executive Sponsors.    
Step 2.  MOUD Baseline Assessment: Baseline 
will include buprenorphine, naltrexone & 
methadone capacity and Organizational 
Readiness Baseline Assessment.  Assessment 
and reporting will be completed by Executive 
Sponsor or an administrator. 
Step 3. Train Change Leader & Change Team: 
One Change Leader and up to 7 members 
identified by the organization (Change Team) 
will be trained to implement MOUD during 
the site visit or introductory call with the site 
change team.    
Step 4. Monitor Progress: Track the number of buprenorphine, naltrexone & methadone capacity and use. 
Step 5. Pilot Test Changes to implement MOUD using Plan Do Study Act (PDSA) approach.    
Step 6. Sustain Successful Changes: Implement a plan to institutionalize gains to not revert to old ways. Leadership 
and medical team will be trained to sustain changes made. 
Scaling up Practice #2: ECHO. The ECHO model connects MOUD prescribers and experts with 
primary care providers and medical teams to promote high-quality MOUD practices. ECHO is 
provided monthly through videoconferences. Experienced MOUD prescribers address topics 
such as counseling strategies, urine test interpretation, and transitioning from buprenorphine, 
naltrexone and methadone. Prescribers assigned to the two study arms that include ECHO will 
participate in 12, one-hour monthly ECHO Videoconferences.  
Ten to eleven prescribers from the two study arms will be asked to volunteer to submit case 
studies. Prescribers who volunteer will receive instructions on how to write the case study and 
will receive a $50 gift card as an incentive. One case study will be reviewed during each ECHO 
videoconference call in addition to a subject presentation.  
Kick-Off Meeting 
Prior to the start of the intervention(s), the Executive Sponsor and/or Change Leader (may also 
include Change Team members), as well as other key stakeholders, will be invited to attend a 
half-day in-person Kick-Off Meeting. The following material will be discussed; 1) Overview of 
Study and AIMs, 2) Current practices at sites, 3) Best Practice Examples, 4) Ways to Expand 
Capacity, and 5) NIATx Process. 
We anticipated holding up to and no more than eight kick-off meetings. Meeting locations will 
be determined based on grouping participating sites that are in close proximity to each other to 
keep travel minimal. 

11 
 
Table 1: Outline of the Four Study Arms & Site Responsibilities: 
ARM
NIATx Coach
ECHO
High-Dose Coaching & ECHO
 
Key stakeholders attend an in-person 
Kick-Off Meeting with Study Team & 
Coaches 
 
4-hour onsite visit  
o 1-hour meeting w/Executive 
Sponsor & tour facility 
o NIATx training with Change 
Leader/Team  
 
11 monthly (one-hour) coaching calls  
 
Prescribers participate 
in 12 monthly (one-
hour) video conference 
calls 
Low-Dose Coaching & ECHO
 
Key stakeholders attend an in-person 
Kick-Off Meeting with Study Team & 
Coaches 
 
One-hour conference call with Executive 
Sponsor 
 
Two-hour NIATx webinar training with 
Change Leader/Team 
 
Three (one-hour) coaching calls at 
months 4, 8, and 12 with Change 
Leader/Team 
 
Prescribers participate 
in 12 monthly (one-
hour) video conference 
calls 
High-Dose Coaching / No 
ECHO 
 
Key stakeholders attend an in-person 
Kick-Off Meeting with Study Team & 
Coaches 
 
4-hour onsite visit  
o 1-hour meeting w/Executive 
Sponsor & tour facility 
o NIATx training with Change 
Leader/Team  
 
11 monthly (one-hour) coaching calls  
Low-Dose Coaching / No ECHO
 
Key stakeholders attend an in-person 
Kick-Off Meeting with Study Team & 
Coaches 
 
One-hour conference call with Executive 
Sponsor 
 
Two-hour NIATx webinar training with 
Change Leader/Team 
 
Three (one-hour) coaching calls at 
months 4, 8, and 12 with Change 
Leader/Team 
 
 
 
 

12 
 
Data Source  
Table 2 shows a complete list of Measures, Sources, and Tool/Frequency.  The Executive 
Sponsor, Change Leader and Change Team at each jail and community-based provider site will 
be asked to complete one or two of the three main surveys based on their role(s) within the 
study: Organizational Survey, Staff Survey, and Physician Survey. Site staff participants will be 
sent links to complete the survey(s) via REDCap. Each organizational site will receive a $1000 
stipend per year for two years once all organizational, physician, and staff surveys have been 
completed.  
 
The trial has 4 study arms that will have staggered starts in order to have sufficient training 
resources for the trial. Each arm will have 12 organizations/sites with N=48 total. 
 
Organizational Surveys & Data:  
Organizational surveys will be completed by Executive Sponsor (or their designee) three times 
during the project (baseline, 12 months and 24 months).  The baseline survey will be conducted 
by phone interview with all 48 sites. To increase survey completion rates for the organizational 
surveys, the research team at UW will conduct follow-up phone calls and e-mails with the 
Change Leaders at Week 1 of post-survey distribution to assure the survey receipt, then at 
Weeks 4 and 12-post survey distribution if surveys are not complete. 
 
We will assess Organizational Traits, Client Traits, Staff Characteristics, and number of 
prescribers at the sites at three points during the study - at organizational baseline (baseline), 
at end of the intervention period (month 12) and at end of sustainability period (24 months) 
using a mix of organizational and administrative data.  
 
Each survey will take approximately 45 minutes to complete. This will result in 48 unique staff 
participants at baseline, and 4 new people per round at post-intervention (m12) and post-
sustainability (m24), assuming 10% turnover at each round. This will result in a total of 56 
unique participants and 144 total surveys. 
 
Staff Surveys & Data:  
The designated Executive Sponsor or the Change Leader at each site will manage staff member 
recruitment to construct a change team of up to a seven (7) member Change Team. Upto two 
of the team members will be physicians. Each member of the change team as well as the 
change leader will be asked to complete staff surveys at baseline, 12m, and 24ms for a total of 
8 “staff” surveys per site.  Information on the implementation process will be gathered from 
site staff members during surveys and interviews.  
 
The full Staff Survey including Organizational Readiness for Implementing Change (ORIC), 
Organizational Climate-Stress, Attitudes toward MOUD and Program Sustainability, will be 
administered three times during the study (baseline, 12m, 24m).  Each survey is expected to 
take approximately 20 minutes or less to complete. Staff completing the surveys will receive 
consent documents when they are sent the survey link via REDCap. To increase survey 

13 
 
completion rates for the Staff Surveys, the research team at UW will conduct follow-up phone 
calls and e-mails with the Change Leaders at Week 1 of post-survey distribution to assure the 
survey receipt, then at Weeks 4 and 12-post survey distribution if surveys are not complete. 
Each survey cycle, at months listed above, will include up to 384 people per cycle. The 384 staff 
will include up to 8 participants from the 48 sites and will include the Change Leader 
(supervisor/member of the leadership staff), and up to 7 team members part of the Change 
Team (CJ staff, prescribers, clinicians, nurses, counselors, social workers, etc). Since many of the 
same staff will likely complete surveys in successive cycles, 536 unique staff are expected for 
survey completion across all three cycles. The 536 unique people projected assumes 20% or 76 
new people per round occurs post-intervention and post sustainability round. There will be a 
total of 1,152 surveys. 
 
Physician Surveys & Data:   
Collecting physician attitudes toward MOUD will occur at months 0, 12, and 24. An average of 
two prescribers are anticipated per site. Each survey will take 15 minutes or less to complete. 
Staff completing the surveys will receive consent documents when they are sent the survey link 
via REDCap. To increase survey completion rates for the Physician Surveys, the research team 
at UW will conduct follow-up phone calls and e-mails with the physicians at Week 1 of post-
survey distribution to assure the survey receipt, then at Weeks 4 and 12-post survey 
distribution if surveys are not complete. This will result in 96 unique prescriber participants at 
baseline, and 9 new people per round at post-intervention (m12) and post-sustainability (m24), 
assuming 10% turnover at each round. This will result in a total of 114 unique prescribers and 
288 surveys (@ 96/cycle). 
  
The grand total of organizational surveys, at n=144, staff surveys at n=1,152, physician 
surveys at n=288. TOTAL will be N=1,584.  
  
Administrative & Site Aggregate Data:  
 
Administrative Jail Data will be collected from all 24 jail sites once every year for two years. We 
anticipate the data will include de-identified screening, assessment and/or intake data, 
demographic information, date entered/exited jail, sentence and length, etc. 
Administrative State Criminal Justice Data will be obtained from state databases for all states 
that have a jail/community-based provider participating in the study. De-identified data will be 
provided once every year for two years for the participating jail jurisdictions (e.g. in Wisconsin it 
is counties). Data may include arrest dates, arrest offenses, court outcomes, sentence and 
length, etc.  
Health and Treatment Provider Data will be provided by all 24 community-based treatment 
providers once every year for two years. De-identified data for jail based referrals would 
include number of referrals to OUD care, number of referrals to behavioral therapy or 
counseling, dates/type of care, MOUD units received, Medicaid payment data, etc. 
Monthly Tracking Data will be provided by all 48 jails/community-based treatment providers on 
a monthly basis via spreadsheet provided by study team. Captured data for the jails will include 
MOUD treatment data, number screened for OUD, number receiving MOUD, number of 

14 
 
individuals who received naltrexone, buprenorphine and methadone and number of 
injections/slots. Captured data for the community-based treatment providers will include 
number referred from the jail for OUD, number receiving MOUD, number of individuals who 
received naltrexone, buprenorphine and methadone and number of injections/slots. 
 
All suggested data requirements are included in the Information Sheet provided to each site 
prior to participation in the study. 
 
Table 2: Measures, Sources, and Tool/Frequency  
 
Measurement 
Measure Source
Data Source/Frequency 
Descriptive Statistics
Organizational traits (survey source): Admissions
(state), Rural v. Urban (state), organizational 
readiness (staff), MOUD type (org), funding (org), 
# of practitioners (org)    
 
Client traits: Age, gender, ethnicity, highest 
education level, employment indicator, place of 
residence, type of offense, 
Medications/Treatment offered (date(s) 
receiving MOUD), mental health comorbidity, 
OUD history, Disciplinary actions/incident 
reports, types of offenses 
 
Staff Characteristics: Age, Gender, Ethnicity, 
Certification or education level, years of training, 
tenure on the job 
Organization &
Administrative 
Data 
 
Organizational Survey  
o Baseline, 12m, 24m 
 
 
 
 
 
State CJ Database & Jail 
Administrative Database 
o Baseline, 12m, 24m 
 
Monthly Tracking Site Spreadsheet 
 
 
 
 
 
Organizational Survey 
Baseline, 12m, 24m 
Reach
% of patients initiated/begin MOUD; Days 
engaged in MOUD  
Organization
 
Monthly Tracking Site Spreadsheet 
o Completed by Jail/Clinic 
Manager/Data Liaison 
 
Or State Databases 
Effectiveness
Re-Arrest Data: Arrest dates, Arrest Offense 
(charge), Felony/Misdemeanor indication, 
Outcome (convicted, not convicted, sentence, 
start and end date of sentence),  
 
State Database
 
State CJ databases 
o Baseline, 12m, 24m 

15 
 
Adoption
% of prescribers using MOUD
 
 
Staff Attitudes Toward MAT 
 
 
 
Physician Satisfaction with MOUD 
Organization
 
 
Knudsen, 
Ducharme, Roman 
& Link42 
 
 
Modified Physician 
Worklife Survey 
 
Organizational Survey 
o Baseline, 12m, 24m 
 
 
Staff Survey 
o Baseline, 12m, 24m 
 
 
 
Physician Survey 
o Baseline, 12m, 24m 
Implementation
Organizational Readiness for MOUD
 
 
Organizational Climate: Stress 
ORIC39
 
 
TCU SOF41 
 
Organizational Survey 
o Baseline, 12m, 24m 
 
 
Staff Survey 
o Baseline, 12m, 24m 
Maintenance
Likelihood of MOUD sustainability
 
 
 
NIATx Fidelity & ECHO Fidelity 
 
Program 
Sustainability 
Assessment Tool40 
 
Organization 
(using a scale 
designed for this 
study) 
 
 
Staff Survey 
o Baseline, 12m, 24m 
 
 
 
Organizational Survey 
o Baseline, 12m, 24m 
 
 
Qualitative Interviews  
Qualitative data will be gathered from organizational staff at two points; pre-intervention (baseline) and 
post-intervention (12 months). 
 
Baseline qualitative phone interviews will be completed with leadership staff at 24 randomly selected 
sites, six sites within each study arm. Interviews will last approximately 30-45 minutes in length and will 
be conducted with up to two people at each site. The interviews will be audio-taped (with staff 
participant permission), but the staff person’s identity will be protected and in no way be linked to the 
results.  Interviews will be semi-structured and gather information that is not included within the 
organizational surveys that will be completed throughout the study. This includes information about site 
structure and process, culture surrounding justice-involved clients, motivation for serving OUD 
population and approaches to organizational change. Examples of open-ended questions that will be 
asked; 

16 
 
1. Please walk me through how a justice-involved client comes to your service? 
2. Are your justice-involved clients integrated into your general clientele? 
3. Please tell me about the last time your organization made a change to its processes? 
Post-intervention qualitative phone interviews at 12 months will be conducted with the Change Leader 
at 24 selected sites. Interviews will last approximately 20-30 minutes and will be audio-taped (with staff 
participant permission), but the staff person’s identity will be protected and in no way be linked to 
results.  Sites will be chosen by taking the three highest achieving sites and the lowest achieving sites in 
each of the four arms, providing for 24 interviews. Sites will be ranked based on the percentage of 
eligible individuals who received MOUD within the 12-month intervention period. During the interview, 
Change Leaders will be asked to review their site outcome data and provide their experience and 
feedback about the implemented intervention(s). 
Example of open-ended questions included; 
1. What do you see when you look at this data from your site? 
2. What helped you to achieve these results? 
3. What barriers got in the way? 
We will use University of Wisconsin Box to store data received from all sites.  
Unanticipated events  
Should any unanticipated problems arise, they will be reported to WIRB per the appropriate IRB’s 
guidance on unanticipated problems and reportable events.  
  
Privacy and Confidentiality  
Since community-based organizations and jail sites will play a role in the testing of the NIATx and ECHO 
interventions, we view staff members as human subjects. For the project’s evaluation plan, we will 
address human subjects’ protection for staff. Clients are not being addressed since they are not the 
focus of the intervention, while the organization’s leadership, staff and prescribers are. The data to be 
collected in the evaluation will come from existing de-identified client data collected in state 
administrative databases as well as organizational and staff surveys, and staff interviews. Table 3 
(below) briefly describes the individuals referred to in the protection plan who will have access to the 
project data and their level of access.   
 
 
 
 
 
 
 
 
 
 
 
 
 

17 
 
Table 3: Research Participant Overview   
Title 
Affiliation 
Access 
Scientific Directors (PI) 
UW-Madison & George 
Mason University 
Limited Data Set client administrative 
data, survey, and interview data   
Project Team 
(researchers/students)  
UW-Madison & George 
Mason University 
Limited Data Set client administrative 
data, survey, and interview data  
State database administrators
States with 
participating sites 
They will not receive or view any 
administrative, survey, or interview 
data 
Executive Sponsor
(Site staff member in 
administration, executive or 
management role)  
Participating sites
They will not receive or view any 
administrative, survey, or interview 
data  
Change Team Leader
(Site staff member in a 
management role) 
Participating sites
They will not receive or view any 
administrative, survey, or interview 
data  
Change Team
(Site staff members-Prescribers 
(at least one), clinicians, nurses, 
counselors, social workers, etc) 
Participating sites
They will not receive or view any 
administrative, survey, or interview 
data 
  
7. POTENTIAL RISKS 
Staff level:  
Staff members could feel pressure to participate in the study. It will be made clear, through written 
materials and oral instruction, that staff participation in the project’s evaluation is completely voluntary. 
The cost and implementation analyses and their purpose in understanding the feasibility of 
implementing NIATX and ECHO will be explained. Staff responses to interviews will be coded and 
responses will be accessible only by evaluation team members (survey and interview data will not be 
accessible to other clinic staff members). In addition, the Executive Sponsor for each site will be notified 
of the importance of staff not feeling coerced to participate in the study or complete staff surveys.   
The potential risk for staff is that the information they provide could be offensive to members of 
management or their peers. Hence, protecting staff confidentiality is an important element of our 
protection plan. Researchers (Jacobson, Vechinski, Breno) trained in protecting consumer confidentiality 
will conduct interviews. Data collected in the interviews and surveys will have a code number assigned 
(as previously defined) attached prior to storing in the project dataset. In this way, we can ensure that 

18 
 
the interviewer (in the case of interviews) and the University of Wisconsin database administrator (in 
the case of surveys) will be the only person who can identify the interviewee’s responses. Also, 
managers or other members of the organization will not see transcripts of interviews.  
In summary, during the on-line consent, potential subjects will be informed of (1) the nature and 
purpose of the study, (2) the types of data that will be collected from, (3) measures taken to insure the 
confidentiality of data collected (4) their right to leave the study at any time, and (5) the timeline of the 
study. Consent will be documented by obtaining online IRB-approved consent forms containing all of the 
above information. Consent forms will be digitally based. Consent forms will be stored at the University 
Wisconsin – Madison on a secure server.  The consumer can download a PDF of the consent form.  
 
A Certificate of Confidentiality has automatically been granted by virtue of this study being funded 
through the National Institutes of Health.  This provides an additional level of protection for participant 
data. 
 
8. MEASUREMENT OF EFFECT  
All scales used in this study, except for the Fidelity scales developed for this study, have good tested 
psychometric properties with similar populations. Listed below are the factors to be measured and 
measurement instruments with references to validation studies.  
Descriptive Statistics - Organizational traits such as admission and rural v. urban will be obtained via 
Organizational Survey and database. Client traits such as age, gender, ethnicity, treatment offered and 
CJ status will also be obtained at three points during the study via the Organizational Survey and 
database. Staff traits such as gender, ethnicity, and certification or education level will be obtained via 
the Organizational Survey at three points. 
 
REACH  - The percent of patients initiated on MOUD and length of engagement will be obtained through 
monthly spreadsheet data completed by organizational staff or state databases.   
Adoption – The percent of prescribers using MOUD will be collected through the Organizational survey 
at 3 points during the study. The organizations readiness for MOUD will be collected using the 
Organizational Readiness for Implementing Change (ORIC) scale and the Organizational Climate: Stress 
measure will be collected at two points in the study. 
Effectiveness – Re-arrest rates will be obtained through state police databases on a yearly basis.   
Maintenance –The organizational survey, which will be administered at three points during the study, 
will assess the likelihood of MOUD sustainability. The Physician Survey will be completed by physicians 
at 3 points during the study. 
 
9. STUDY PARAMETERS  
The 48 participating jails or community-based organizations will be assigned to one of four study arms; 
• 
High-Dose Coaching & ECHO; community-based organizations (n=9), jails (n=3)    
• 
Low-Dose Coaching & ECHO; community-based organizations (n=9), jails (n=3)    
• 
High-Dose Coaching & No ECHO; community-based organizations (n=9), jails (n=3)    
• 
Low-Dose Coaching & No ECHO; community-based organizations (n=9), jails (n=3)    

19 
 
We will use a matching strategy that groups four clinics together prior to randomization. One clinic from 
each four-clinic matched group will be randomized to each study arm. The matching criteria, using 
organizational characteristics traits, are:   
a) Referral Source 
b) Whether or not currently providing MOUD to CJ populations 
c) Admissions per year 
d) Urban vs Rural 
 
10. STATISTICAL CONSIDERATIONS  
Sample Size & Power:   
Regarding the two intervention factors, coaching and ECHO, in 2x2 factorial design conditions, we will 
recruit 48 programs, including 16 jails and 32 community-based organizations in the criminal justice 
system (CJS). This number provides reasonable power to detect the effects of coaching and ECHO on 
primary outcomes, as previous research indicates estimated effect sizes for the former as medium and 
the latter as large.  A buprenorphine implementation study conducted in 48 treatment agencies in Ohio 
found that NIATx coaching increased MOUD adoption rates by 24.8% (Molfenter, Quanbeck, et al 2013). 
More recently, PI Molfenter found that High vs. Low-Dose coaching provided significantly different 
results on increases in buprenorphine use among 20 organizations (31.5% vs. 2.5%, p = .001, Cohen’s d = 
.5136). Other researchers have found large effects for ECHO, including a 10-fold increase in 
buprenorphine waivered physicians (Komaromy M, Duhigg D, Metcalf A, et al. 2016).  Therefore, our 
power analysis focuses on detecting High- vs. Low-dose coaching effects with an estimated effect size of 
d = .51.  Patient outcomes within the same programs may not be independent due to the clustered 
nature of the data. Based on previous studies, we anticipate the intra-class correlation (ICC) to be 
around 0.10. Although the number of patients within programs will likely vary over time, our current 
and previous studies with similar populations and designs suggest that we can anticipate the number of 
participating programs to be mostly stable during the study period.  To increase survey completion, 
programs will be given a $1,000 bonus for providing a year of data per site; for government agencies we 
will provide program materials such as wrist bands, stress balls, or other items to share with 
participants. This approach is yielding a return rate of 89% in a current study. With 42 programs at the 
end of the study after 11% attrition and 75 or more patients per program, we will be able to detect 
coaching effects at a power of .85 or higher in our proposed study with a Type I error rate of 0.05. The 
corresponding power for ECHO would be greater (.90+) with the same number of programs and 
patients. Power analysis software developed for clustered data, Optimal Design, was used to calculate 
power. 
Data Analysis Plan: 
Initial exploratory analyses of MOUD initiation and use will assess standard summary statistics and 
examine graphical representations of the data and will compare baseline characteristics among the 48 
participating programs in this study, including patient age, ethnicity, nature of SUD, criminal justice 
status, organizational readiness for change, and MOUD. Chi-square and t-tests will be used to test for 
statistically significant baseline differences. Descriptive statistics and figures will display the distribution 
of each analytic variable collected at each time point.  

20 
 
The rates and frequency of MOUD use (buprenorphine, methadone and injectable naltrexone) will be 
measured repeatedly, and these values will be correlated over time. Instead of assuming independence 
(i.e., zero correlation) or a compound symmetry covariance structure (i.e., a constant correlation 
regardless of the proximity of measurement time points), we will allow errors to be auto-correlated or 
Toeplitz-structured, denoted as AR(p) or TOEP(p), in growth curve models. The best-fitting covariance 
structure will be determined based on heuristic model comparison criteria such as AIC and BIC. 
Intervention and Sustainability: 
For MOUD and implementation outcomes at 12 month and at 24 month, mixed-effects models (random 
effects of programs; fixed effects of treatment condition and time) will be used for data analysis. Mixed-
effects models, also known as multilevel or hierarchical linear models, are suitable because MOUD 
patients are nested within programs. Using a multilevel modeling framework, separate models will be 
applied for the percentage of patients and clinicians using MOUD and their frequency of use (for 
patients only). Program covariates as well as variables showing noticeable changes between phases will 
be included in the models as covariates to properly and efficiently estimate the effects of coaching and 
ECHO. We will examine the coaching and ECHO effects at each time point using cross-sectional 
multilevel models and will also implement growth curve models across time that include the coaching 
(high vs. low) and ECHO (present vs. absent) effects, time (baseline, post intervention, follow-up), and 
interactions between the intervention and time factors, while controlling for relevant time-varying and 
time-constant covariates.  The rates and frequency of MOUD use (by buprenorphine, methadone and 
injectable naltrexone) and clinical and implementation outcomes will be measured repeatedly for the 
same programs, and it is expected that these values will be correlated over time. Therefore, instead of 
assuming independence (i.e., zero correlation) or a compound symmetry covariance structure (i.e., a 
constant correlation regardless of the proximity of measurement time points), we will allow errors to be 
auto-correlated or Toeplitz-structured,82 denoted as AR(p) or TOEP(p), in the growth curve models. The 
best-fitting covariance structure will be determined based on heuristic model comparison criteria such 
as AIC and BIC. 
Mediational analysis:  
We will examine the mediating effects of organizational factors on MOUD use through: NIATx Fidelity, 
ECHO Fidelity, the Organizational Readiness for Implementing Change (ORIC), Program Sustainability 
Assessment, and the Organizational Climate (Stress) measure.  These factors will be analyzed using 
mixed-effects models. Through a mediation analysis, we can estimate the direct (NIATx and ECHO) and 
indirect effects (Adoption - # of prescribers) of each implementation arm. 
We will test the mediation effect of each potential mediator at each time point as well as across time. 
The R package ‘mediation,’ will estimate the causal mediation effects, examine moderated mediation 
effects, and conduct sensitivity analysis.70 
Effectiveness analysis:  
We will compare MOUD use and retention rates in the 4 different arms using hierarchical linear models, 
where arm membership is used as the treatment assignment. We will examine the distribution of this 
outcome measure and will implement an appropriate transformation or nonlinear link function when 
appropriate (e.g., logistic, Poisson, exponential). Monthly data collection of the Effectiveness as well as 
Reach (MOUD use) measures, allows for analysis after each stage of NIATx and ECHO. 
 
 

21 
 
Table 4: Initiation & Retention 
Data
Source
Initiation
 
 
# of clients initiated on MOUD 
 
# on MOUD 
Organizational Spread Sheet
Retention
 
# of injections 
 
# of weeks on Buprenorphine 
(30-Day Discontinuation) 
 
# of methadone doses 
State Database
 
Qualitative Analysis:  
The qualitative analysis will be conducted by project staff, supervised by the qualitative methodologist, 
who will ensure that proper and consistent interviewing and analysis techniques are used.  Project staff 
will conduct the interviews, which will be audio recorded and transcribed verbatim. Interviews with 
leadership personnel will focus on organizational culture, including the organization’s approach to 
making process changes, as well as motivations and expectations for working with justice-involved 
populations. Interviews with staff will focus on the staff’s perspectives on their organizations’ 
experiences with identifying and implementing process changes. Project staff will conduct a directed 
content analysis of these data. Qualitative data will be summarized and analyzed to detect patterns in 
individual and clinical approaches to change that have been successful. This description will enhance our 
understanding of how the NIATx and ECHO models work in criminal justice settings and criminally 
involved populations, promoting valuable insights that can be applied to future dissemination and 
implementation of evidence-based practices. 
 
11. RECORDS TO BE KEPT  
• 
Organizational traits  
• 
Staff/client traits  
• 
Survey results (Organizational, staff and physician surveys)  
 
 
 
 
 
 
 
 
 
 

22 
 
12. ACRONYM LIST  
  
BJA 
Bureau of Justice Assistance 
CFIR  
 
Consolidated Framework for Implementation Research  
 
CJ 
Criminal Justice 
CHESS  
 
Center for Health Enhancement System Studies  
 
CSAT 
Center for Substance Abuse Treatment 
D/I 
Dissemination and Implementation 
EBPs 
Evidence-Based Programs 
ECHO 
Extension for Community Healthcare Outcomes 
MAT 
Medication Assisted Treatment 
MOUD 
Medications for Opioid Use Disorder 
NIATx 
 
Network for the Improvement of Addiction Treatment
OCM  
 
Organizational Change Manager  
 
OUD 
Opioid Use Disorder 
PDSA  
 
Plan-Do-Study-Act  
 
RCT  
 
Randomized Control Trials  
 
RE-AIM  
 
Reach, Effectiveness, Adoption, Implementation, Maintenance  
 
SAMHSA 
Substance Abuse and Mental Health Services Administration 
SUD  
 
Substance Use Disorder  
 
TAU  
 
Treatment as Usual  
 
  
 
 
 
 
 
 
 
 
 
 

23 
 
13. REFERENCES CITE 
 
1.  
Fearn NE, Vaughn MG, Nelson EJ, Salas-Wright CP, DeLisi M, Qian Z. Trends and correlates of 
substance use disorders among probationers and parolees in the United States 2002–2014. Drug 
Alcohol Depend. 2016;167:128-139. doi:10.1016/j.drugalcdep.2016.08.003 
2.  
Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose 
deaths in Baltimore, Maryland, 1995-2009. Am J Public Health. 2013;103(5):917-922. 
doi:10.2105/AJPH.2012.301049 
3.  
Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or 
methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2). 
doi:10.1002/14651858.CD002207.pub4 
4.  
Saloner B, Karthikeyan S. Changes in Substance Abuse Treatment Use Among Individuals With 
Opioid Use Disorders in the United States, 2004-2013. JAMA. 2015;314(14):1515-1517. 
doi:10.1001/jama.2015.10345 
5.  
Wu L-T, Zhu H, Swartz MS. Treatment utilization among persons with opioid use disorder in the 
United States. Drug Alcohol Depend. 2016;169:117-127. doi:10.1016/j.drugalcdep.2016.10.015 
6.  
Kaeble D, Glaze L. Correctional Populations in the United States, 2015. 2016. 
https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5870. Accessed February 12, 2019. 
7.  
Minton T, Zeng Z. Jail Inmates in 2015. 2016. https://www.bjs.gov/content/pub/pdf/ji15.pdf. 
Accessed February 13, 2019. 
8.  
Kaeble D, Bonczar T. Probation and Parole in the United States, 2015. 2016. 
https://www.bjs.gov/content/pub/pdf/ppus15.pdf. Accessed February 13, 2019. 
9.  
Bronson J, Berzofsky M. Indicators of Mental Health Problems Reported by Prisoners and Jail 
Inmates, 2011-12. 2017. 
https://pdfs.semanticscholar.org/f4ad/2be77c5a5f7a5e6e45958d4e1c8bdd4e2af7.pdf. Accessed 
February 14, 2019. 
10.  Bronson J, Stroop J, Zimmer S, Berzofsky M. Drug Use, Dependence, and Abuse Among State 
Prisoners and Jail Inmates, 2007-2009. 2017. 
https://www.bjs.gov/content/pub/pdf/dudaspji0709.pdf. Accessed February 13, 2019. 
11.  Hartwell SW. Comparison of Offenders With Mental Illness Only and Offenders With Dual 
Diagnoses. Psychiatr Serv. 2004;55(2):145-150. doi:10.1176/appi.ps.55.2.145 
12.  Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ. Psychiatric Disorders and Repeat 
Incarcerations: The Revolving Prison Door. Am J Psychiatry. 2009;166(1):103-109. 
doi:10.1176/appi.ajp.2008.08030416 
13.  Jordan B, Schlenger W, Fairbank J, Caddell J. Prevalence of psychiatric disorders among 
incarcerated women: II. Convicted felons entering prison. Arch Gen Psychiatry. 1996;53(6):513-
519. 

24 
 
14.  Teplin LA, Abram KM, Mcclelland GM. Prevalence of Psychiatric Disorders Among Incarcerated 
Women: I. Pretrial Jail Detainees. Arch Gen Psychiatry. 1996;53(6):505. 
doi:10.1001/archpsyc.1996.01830060047007 
15.  Lurigio A. Effective services for parolees with mental illnesses. Crime Delinquency. 2001;47(3):446-
461. 
16.  Baillargeon J, Williams BA, Mellow J, et al. Parole Revocation Among Prison Inmates With 
Psychiatric and Substance Use Disorders. Psychiatr Serv. 2009;60(11):1516-1521. 
doi:10.1176/ps.2009.60.11.1516 
17.  Crilly JF, Caine ED, Lamberti JS, Brown T, Friedman B. Mental Health Services Use and Symptom 
Prevalence in a Cohort of Adults on Probation. Psychiatr Serv. 2009;60(4):542-544. 
doi:10.1176/ps.2009.60.4.542 
18.  Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. 
Addiction. 2006;101(2):181-191. doi:10.1111/j.1360-0443.2006.01316.x 
19.  Lurigio AJ, Cho YI, Swartz JA, Johnson TP, Graf I, Pickup L. Standardized Assessment of Substance-
Related, Other Psychiatric, and Comorbid Disorders among Probationers. Int J Offender Ther Comp 
Criminol. 2003;47(6):630-652. doi:10.1177/0306624X03257710 
20.  Hayes LM, Rowan JR. National Study of Jail Suicides: Seven Years Later. Alexandria Va: National 
Center on Institutions and Alternatives; 1988. 
21.  Charles DR, Abram KM, Mcclelland GM, Teplin LA. Suicidal Ideation and Behavior Among Women 
in Jail. J Contemp Crim Justice. 2003;19(1):65-81. doi:10.1177/1043986202239742 
22.  Sarchiapone M, Jovanović N, Roy A, et al. Relations of psychological characteristics to suicide 
behaviour: Results from a large sample of male prisoners. Personal Individ Differ. 2009;47(4):250-
255. doi:10.1016/j.paid.2009.03.008 
23.  Bronson J, Maruschak L, Berzofsky M. Disabilities Among Prison And Jail Inmates, 2011-12. 2015. 
https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5501. Accessed February 13, 2019. 
24.  Mallik-Kane K, Visher CA. Health and Prisoner Reentry: How Physical, Mental, and Substance Abuse 
Conditions Shape the Process of Reintegration. 2008:82. doi:10.1037/e719772011-001 
25.  Fazel S, Baillargeon J. The Health of Prisoners. The Lancet. 2011;377(9769):956-965. 
doi:10.1016/S0140-6736(10)61053-7 
26.  McNiel DE, Binder RL, Robinson JC. Incarceration Associated With Homelessness, Mental Disorder, 
and Co-occurring Substance Abuse. Psychiatry Serv. 2005;56(7):840-846. 
doi:10.1176/appi.ps.56.7.840 
27.  Binswanger IA, Stern MF, Deyo RA, et al. Release from Prison — A High Risk of Death for Former 
Inmates. N Engl J Med. 2007;356(2):157-165. doi:10.1056/NEJMsa064115 

25 
 
28.  Merrall ELC, Kariminia A, Binswanger IA, et al. Meta-analysis of drug-related deaths soon after 
release from prison: Drug-related deaths after release from prison. Addiction. 2010;105(9):1545-
1554. doi:10.1111/j.1360-0443.2010.02990.x 
29.  Stein BD, Sorbero M, Dick AW, Pacula RL, Burns RM, Gordon AJ. Physician Capacity to Treat Opioid 
Use Disorder With Buprenorphine-Assisted Treatment. JAMA. 2016;316(11):1211-1212. 
doi:10.1001/jama.2016.10542 
30.  Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies--tackling the opioid-
overdose epidemic. N Engl J Med. 2014;370(22):2063-2066. doi:10.1056/NEJMp1402780 
31.  Brinkley-Rubinstein L, Zaller N, Martino S, et al. Criminal justice continuum for opioid users at risk 
of overdose. Addict Behav. 2018;86:104-110. doi:10.1016/j.addbeh.2018.02.024 
32.  Krawczyk N, Picher CE, Feder KA, Saloner B. Only One In Twenty Justice-Referred Adults In 
Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine. Health Aff (Millwood). 
2017;36(12):2046-2053. doi:10.1377/hlthaff.2017.0890 
33.  Friedmann PD, Wilson D, Knudsen HK, et al. Effect of an Organizational Linkage Intervention on 
Staff Perceptions of Medication-Assisted Treatment and Referral Intentions in Community 
Corrections. J Subst Abuse Treat. 2015;50:50-58. doi:10.1016/j.jsat.2014.10.001 
34.  Balas EA. From appropriate care to evidence-based medicine. Pediatr Ann. 1998;27(9):581-584. 
35.  Molfenter T, Kim J-S, Quanbeck A, Patel-Porter T, Starr S, McCarty D. Testing use of payers to 
facilitate evidence-based practice adoption: protocol for a cluster-randomized trial. Implement Sci. 
2013;8(1). doi:10.1186/1748-5908-8-50 
36.  Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, N.J: L. Erlbaum 
Associates; 1988. 
37.  Komaromy M, Duhigg D, Metcalf A, et al. Project ECHO (Extension for Community Healthcare 
Outcomes): A new model for educating primary care providers about treatment of substance use 
disorders. Subst Abuse. 2016;37(1):20-24. doi:10.1080/08897077.2015.1129388 
38.  Hsieh FY, Lavori PW, Cohen HJ, Feussner JR. An overview of variance inflation factors for sample-
size calculation. Eval Health Prof. 2003;26(3):239-257. doi:10.1177/0163278703255230 
39.     Shea, C.M., Jacobs, S.R., Esserman, D.A. et al. Organizational readiness for implementing change: a 
psychometric assessment of a new measure. Implementation Sci 9, 7 (2014) doi:10.1186/1748-
5908-9-7 
40.     Center for Public Health Systems Science; George Warren Brown School of Social Work. Program 
Sustainability Assessment Tool. Washington University, St. Louis. http://www.sustaintool.org. 
August 2013. 
41.     Institute of Behavioral Research. (2003). TCU Organizational Readiness for Change: Treatment 
Staff Version (TCU ORC-S). Fort Worth: Texas Christian University, Institute of Behavioral Research. 
Available at ibr.tcu.edu. 

26 
 
42.     Knudsen, Ducharme, Roman & Link (2005). Buprenorphine diffusion: The attitudes of substance 
abuse treatment counselors. JSAT 29(2):95-106.