Addressing the Syndemic of Addiction, COVID-19, and Structural Racism by Strengthening the Workforce



By Sara Becker 
New England ATTC

According to the latest data from the Centers for Disease Control and Prevention, over 105,000 Americans have died and at least 1.7 million Americans have been infected with the novel coronavirus disease (COVID-19). Social distancing measures put in place to contain the spread have decimated entire sectors of the United States economy, with the stock market dropping so precipitously that it erased three years of gains. Unemployment rates are also at historically high levels with the national rate rapidly approaching 15%. In a few short months, COVID-19 has upended our country and harmed millions of Americans.

Data on the toll of COVID-19 are troubling in aggregate, but even more concerning when we consider those Americans hit the hardest. Recent commentary by NIDA director Nora Volkow (2020) underscored how individuals who use opioids are at increased risk for the most adverse consequences of COVID-19 due to both direct (e.g., slowed breathing due to opioid use) and indirect (e.g., housing instability, incarceration) pathways. In addition, Black Americans and Hispanics have been disproportionately affected by COVID-19: emerging regional data suggests that the COVID-19 death rate for Black and Hispanic Americans is about 2.5 times higher than for whites. The disproportionate toll of disease reflects the effects of structural racism, which manifests in increased risk of underlying health conditions (e.g., chronic respiratory disease); decreased access to testing and care; and decreased ability to socially isolate due to factors such as crowded living conditions and employment in sectors deemed essential. Taken together, these data indicate that the United States is in the midst of a syndemic - defined as the interaction of a set of linked health problems involving two or more conditions, interacting synergistically and contributing to excess burden of disease. Addressing the syndemic of addiction, COVID-19, and structural racism requires responses on multiple levels and across multiple fronts. One of those fronts is ensuring that the addiction treatment workforce is equipped with the tools needed to help patients facing these interacting epidemics.

The Addiction Technology Transfer Center (ATTC) Network has been working to meet this challenge by developing new products and resources focused on these intertwined public health issues. The National Coordinating Office hosted a Listening Session and a 5-part Strategic Discussion Series focused on emerging issues around COVID-19 and social determinants of health. The Listening Session solicited feedback on ways COVID-19 has highlighted racial and ethnic disparities, and each Strategic Discussion focused on concrete actions that could be taken to support specific communities of color.

Regional ATTCs have also risen to the challenge to create new tools for the addiction workforce during these unprecedented times. The New England ATTC has developed multiple products including a 2-part webinar series (in partnership with the New England Mental Health Technology Transfer Center) focused on the intersection of addiction, mental health, and COVID-19; a training focused on Trauma-Informed Approaches to Substance Use Assessment and Intervention (which includes new content on how to sensitively assess and address the trauma of racism and the traumas inflicted by COVID-19); and a workshop on Cultural Intelligence and Cultural Humility (which has been adapted to address the disparities and racism highlighted by COVID-19). The New England ATTC has also partnered with the South Africa HIV ATTC to develop a series of products focused on provider self-care in recognition of the toll that caretaking places on front-line health professionals. Finally, in October 2020 the New England ATTC will proudly host this year’s national Addiction Health Services Research Conference (delivered fully virtually)! One of the plenary talks by Dr. Ayana Jordan will specifically address the intersection of structural racism and addiction, and spotlight awards will be given to addiction researchers from underrepresented minority groups.

The New England ATTC is proud to join other Regional ATTCs in not only building the skills of the SUD workforce but also providing supportive strategies for sustaining hope and encouraging self-compassion during this trying times. Please visit the New England ATTC’s COVID-19 resource page to see the latest products and training events devoted to addressing this syndemic.

How to Reduce No-shows to Virtual Appointments

Director, Great Lakes ATTC, MHTTC, and PTTC

Is this a familiar scenario for your organization?
Day 1: Stay-at-home order: Your agency enacts social distancing guidelines.

Day 3: Your agency has switched in-person counseling to telephonic or video-based counseling.

Day 12: Virtual services, particularly telephone, have increased engagement rates!

Day 30: The honeymoon is over: show rates to virtual appointments are decreasing, especially among new consumers.

In the COVID-19 era, an old nemesis has returned: appointment no-shows. While telehealth has removed some barriers to behavioral health services, other engagement challenges are emerging. Agencies can take the “how exactly are we going to do this?” approach that COVID-19 has thrust us into since the beginning.

Another way is to turn to existing tools and proven practices to address the new no-show dilemma.

Three Tips to Reducing No-Shows During COVID-19 and Beyond
Apply these three tips, in this order, and watch your no-show rates decrease and show-rates increase.

1. Track No-Show Performance 

You can’t improve what you do not measure. No-shows should be measured. Measure no-shows to virtual appointments the same way you measured no-shows to in-person appointments before COVID-19. Compare no-show rates pre- and post- COVID. Segment the data as needed: new vs. existing client; by client age; by appointment type, etc. This measurement creates a foundation for improvement.

2. Use PDSA Cycles!

The Plan-Do-Study-Act (PDSA) method creates a simple process to test new approaches and observe their impact on no-shows. (See related post from NIATx coach Mat Roosa: Learning from Crisis: PDSA in Times of Challenge.) Plan a change; Do a change; Study the impact of the no-shows; then, Act on the change. (Adopt, adapt, or abandon.) You can conduct PDSA Cycles as part of an organized agency-based improvement initiative. Or, individual clinicians can perform PDSA cycles to improve their show rates.

What are good practices for addressing no-shows in a PDSA cycle? See Tip 3:

3. Use Proven Practices to Reduce No-shows
While COVID-19 provides us with some very new situations, we can learn a lot from what’s worked in the past to reduce no-shows.

Open scheduling: Book appointments to accommodate consumers’ schedules. Evening hours? Weekend hours? Ask the consumer, “When would you like us to talk next?”

Reminder calls, e-mails, and text messaging work for virtual appointments as well as they do for in-person appointments. Note the scheduling of the reminder message or text: Two days prior seems to work best for in-person appointments; one day before or on the day of for virtual appointments.

Evidence-Based Practices to Reduce No-Shows

Use Motivational Interviewing (MI) to reduce no-shows by increasing the consumer’s interest in coming back. The growing evidence base for MI shows its effectiveness in a variety of settings.

Use incentives or Contingency Management. Contingency Management is proving to be an effective EBP to enhance retention, particularly for stimulant use disorders. Offer consumers an incentive to reward attendance: a recognition certificate, gift card, or other small prizes.

Learn more about Motivational Interviewing and Contingency Management through the free online courses available through HealtheKnowledge, the ATTC Network’s online learning portal.

Patient no-show trend analysis can identify high-risk no-show patient categories (new vs. existing patients, payer source, patient age) as well as situations (day of the week, time of day, location). Develop patient scheduling practices to increase show rates from identified areas. This practice is particularly relevant as we need to understand better when, where, and how virtual appointments have greater participation.

Interested in learning more about how you can use these tips to reduce no-shows in your organization? Watch for information on the new Virtual NIATx Change Leader Academy—details available soon on the Great Lakes ATTC, MHTTC, and PTTC websites.

What have you found most useful in increasing participation in virtual care? What conditions and practices hurt appointment attendance? What have helped? Let us know in the comment section below.

Dr. Todd Molfenter is the deputy director of the Center for Health Enhancement Systems Studies at the UW-Madison. He is also the director of three SAMHSA-funded Technology Transfer Centers: the Great Lakes Addiction Technology Transfer Center, Mental Health Technology Transfer Center, and 
Prevention Technology Transfer Center. Todd specializes in implementation science, with a particular focus on technology and evidence-based practices in behavioral health.

South Southwest ATTC: Implementing Remote Technology In a Time of Crisis




Maureen Nichols
Director, South Southwest Addiction Technology Transfer Center
HHS Region 6

The recent COVID-19 health pandemic has accelerated the implementation of behavioral health services via remote technology, including telephone and video conferencing. In March 2020, as behavioral health treatment and recovery organizations prepared to continue critical services while implementing social distancing guidelines needed to keep patients and staff safe and healthy, many turned to the use of technology as a solution, including video conferencing and telephone services. For organizational leadership, decisions around critical issues such as compliance with laws and best practices related to patient confidentiality and protection, choice of platforms, licensing and certification regulations for practitioners, and costs and reimbursement procedures, had to be made at an accelerated rate. Federal and state agencies began issuing guidance related to relaxation of enforcement of privacy protections in a limited way due to the short-term health crisis, and funders addressed modifications to reimbursement policies to include telehealth services. However, much of the guidance was necessarily high level, leaving leadership of individual behavioral health programs to assess the fiscal and practical ramifications of responding to the new service landscape via the use of telehealth in the both the short and long term.


Over the past several years, the South Southwest Addiction Technology Transfer Center, in partnership with National Frontier and Rural Telehealth Education Center (NFARtec), has been offering training and technical assistance to states, tribal communities and behavioral health organizations and practitioners as part of its telehealth initiative. This includes documenting best practices and real world examples of implementation, such as the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) successful initiative to increase the uptake of telehealth technologies to deliver assessment, treatment and recovery services in their public health system. It also includes offering behavioral health clinicians and peer support specialists learning collaborative opportunities to build and practice their videoconferencing skills and receive coaching and feedback from experienced behavioral health telehealth practitioners.


At the start of the response to the pandemic, South Southwest ATTC began receiving multiple requests from organizations across the region for immediate guidance on how to translate many of the strategies for remote technology on the ground in a rapid and timely manner. SSW ATTC facilitated regional dialogues between state and local behavioral health organizations with telehealth experience and organizations new to the use of remote technology, including an event in Oklahoma with tribal communities, experienced behavioral health providers and ODMHSAS. Through those discussions, it became apparent that concrete guidance on practical steps for organizations to take in order to implement remote technology was needed. As a result, SSW ATTC developed the Framework for Implementation of Telehealth Services in a Behavioral Health Setting in a Short Time Frame, which covers topics that include:

  • Determining participant interest and capacity for use of technology
  • Selection of technology platforms
  • Patient safety and privacy considerations
  • Staff support and training
  • Review of internal policy and procedures
  • Adapting work flows
  • Fiscal considerations and reimbursements

The goal is to provide a framework for behavioral health care providers that guides organizational leadership through short term practical steps for implementation of remote services via technology while including successful long-term strategies for sustaining telehealth services.





This guide is one piece of a regional and national TTC network partnership designed to provide resources and support to the behavioral health field to ensure services to individuals in our community are accessible, evidence based and culturally responsive during the current challenging health crisis and beyond. Additional resources from the TTC network are available at attcnetwork.org, mhttcnetwork.org and pttcnetwork.org. To access regional assistance from the South Southwest Addiction Technology Transfer Center, please contact us via website or email.


Share Your Perspectives about Opioid Use Disorder among People with Disabilities from Minority Backgrounds




Share Your Perspectives about Opioid Use Disorder among People with Disabilities from Minority Backgrounds.Please click or cut and paste survey link below to participate:

https://www.psychdata.com/s.asp?SID=189204

We are pleased to invite substance, mental health service and vocational rehabilitation professionals (e.g., counselors, clinicians, directors) from across the country that provide to participate in a national study on Opioid Use Disorder Impacts on Employment Prospects for People with Disabilities from minority backgrounds (i.e., African American, Hispanic or Latino, American Indian, Alaskan Native, or Native Hawaiian or other Pacific Islanders). Opioid use disorder (OUD) can involve maladaptive/misuse of prescribed opioid medications, use of diverted opioid medications, or use of illicitly obtained heroin.

This study is being conducted by The Langston University Rehabilitation Research and Training Center (LU-RRTC) on Research and Capacity Building for Minority Entities. Langston University is the only historically black college or university (HBCU). The LU-RRTC is funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).

The new information generated through this study would provide insights on how policy makers, educators and federal research sponsoring agencies such as the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and the National Institutes of Health (NIH) can better respond to the needs of people with opioid use disorder, especially people with disabilities from minority backgrounds. In addition, the study findings may be used as a foundation for developing interventions that seek to improve the experiences and outcomes of individuals with disabilities from minority backgrounds with opioid use disorder.

The information in this study will be used only for research purposes and in ways that will not reveal who you are. Study participants will not be identified in any publication from this study. The survey will take around 20 minutes to complete. If you have any questions or concerns, please contact Dr. Corey Moore (Principal Investigator) via email: corey.moore@langston.edu or Dr. Edward Manyibe (Co-PI) via email: manyibe@langston.edu. If you experience technical difficulty with the survey, contact Dr. Andre Washington: andre.washington@langston.edu and he will be happy to assist you.

Please click or cut and paste survey link below to participate:

https://www.psychdata.com/s.asp?SID=189204

Thank you in advance for your contribution.


How social isolation, loneliness, and insecurity affect people in recovery from addiction and mental illness during COVID-19; and what to do about it


By Pierluigi Mancini, Ph.D.
Project Director, National Hispanic and Latino ATTC


We are going through a difficult period, together, and we are all going through it in our own way. What COVID-19 has done to us as a society is traumatic and the impact of untreated trauma can be subtle, insidious, or outright destructive.

The American Psychiatric Association (APA www.psychiatry.org) reported in a recent survey that almost half of Americans (48%) are anxious about the possibility of contracting coronavirus, COVID-19, that 40% are anxious to get seriously ill or die, and 62% are anxious about the possibility of family and loved ones becoming infected.

It is natural to feel stress, anxiety, anguish and worry during and after a crisis like COVID-19. Each person reacts differently, and their own feelings will change over time. You have to become aware of how you feel and accept it.

Separation from loved ones, loss of freedom, and uncertainty about the state of the disease are cause for concern. Studies have begun to show that most people in social isolation have negative psychological effects, including symptoms of post-traumatic stress, confusion, and anger. The biggest stressors include fears of infection, frustration, boredom, inadequate supplies, inadequate information, financial losses, and stigma.

Lack of connection can cause a feeling of loneliness and is especially aggravated in those recovering from addictions or mental health problems. Each one reacts differently to stressful situations. The typical reactions that occur when sheltering in place due to an immediate problem are different. Some of the emotions that we may be feeling in this situation include anxiety, fear, worry, uncertainty, frustration, sadness, boredom, fear of asking for income or work and negative effects on the ability to sleep well and eat healthy.

The fact of not being able to continue with the routine itself is a factor that disorganizes our structure since we lose the feeling of control. It is important to remember the ability we have to reorganize a new structure.

We can also go through different changes including changes in behavior such as the increase or decrease in energy and activity levels or excessive worry and even the inability to feel pleasure or have fun.

Changes in your body such as stomach pain or headaches or other discomforts or loss or increase in appetite; changes in thoughts like difficulty remembering things or feeling confused. All these symptoms can be interpreted as excuses or reasons to drink or use drugs or to give up and not want to go on.

If the madness of addiction is lived in solitude during its last stages, recovery always occurs with the help and participation of others. And for that we need to build resilience.

The American Psychological Association (https://www.apa.org/topics/resilience) defines resilience as "adaptation to adversity, trauma, tragedy, threats, or major sources of stress."

The concept of resilience helps to understand and promote positive development in situations originally perceived as negative and in potentially destructive challenges. It is the ability to respond to pressures and tragedies quickly, adaptively and effectively, remembering and acknowledging that experience to face future adversities. Applied to humans, resilience is the ability of an individual to develop positively despite adversity. Their goal is to come out strengthened and transformed by the experience, however painful it may be.

We can build resilience using various tools such as focusing on one's strengths, rather than weaknesses; acting on the solutions, and not on the causes of the problem; substituting rigidity for flexibility and recognizing that the past cannot be changed, but that we can learn how it is influencing our present to make the appropriate adjustments today.

For those in social isolation, the general recommendation is to establish a routine with space for leisure and exercise; stay informed through official trustworthy channels like the CDC (www.cdc.gov) and SAMHSA (www.samhsa.gov) and do not overexpose yourself to the news about the coronavirus. It is also recommended to keep in touch with family and friends. It is important to stay connected through social media, but again, with limits. Connections, even if they are virtual, are the great shock absorbers of stress.

We must trust our recovery. What we have achieved so far is worth a lot and you should not forget everything you have done to achieve it. Use your tools, just because you can't go out you don't have to forget them. And in order to relax, start with things you know that help you relax, such as deep breathing, stretching, meditating or praying, or entertaining yourself with a hobby you like.

Do things you enjoy, like reading, listening to music, exercising, or taking a bath; talk about your experience and feelings with loved ones and friends; keep hope and think positively.

And finally, if you need help, please find her. Today we have help available and you can go to www.samhsa.gov where you will find support phones and websites.

[A webinar of this same title is available on our page in English, Spanish and Portuguese. Please visit https://attcnetwork.org/centers/national-hispanic-and-latino-attc/home]



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Cómo el aislamiento social, la soledad, y la inseguridad afecta a las personas en recuperación de adicción y salud mental durante COVID-19; y que hacer al respecto

Por Pierluigi Mancini PhD
Director del Centro Hispano Latino de Capacitación y Asistencia Técnica en Adicción

Estamos pasando por un momento realmente difícil, juntos, y todos lo estamos pasando en nuestra propia manera. Lo que el COVID-19 nos ha hecho como sociedad es traumático y el impacto del trauma que no es tratado puede ser sutil, insidioso o totalmente destructivo.

La Asociación Americana de Psiquiatría (APA www.psychiatry.org) informó en una encuesta reciente que casi la mitad de los estadounidenses (48%) están ansiosos por la posibilidad de contraer coronavirus, COVID-19, que el 40% está ansioso por enfermarse gravemente o morir, y que el 62% está ansioso por la posibilidad de que la familia y los seres queridos se infecten.

Es natural sentir estrés, ansiedad, angustia y preocupación durante y después de una crisis como el COVID-19. Cada persona reacciona de manera diferente y sus propios sentimientos cambiarán a lo largo del tiempo. Hay que tomar conciencia de cómo uno se siente y aceptarlo.

La separación de los seres queridos, la pérdida de libertad, y la incertidumbre sobre el estado de la enfermedad son causantes de preocupación. Estudios han comenzado a demonstrar que la mayoría de las personas que se encuentran en aislamiento social registran efectos psicológicos negativos, incluidos síntomas de estrés postraumático, confusión y enojo. Los mayores factores estresantes incluyen temores de infección, frustración, aburrimiento, suministros inadecuados, información inadecuada, pérdidas financieras y estigma.

La falta de vinculación puede provocar una sensación de soledad y agravarse especialmente en aquellas personas en recuperación de adicciones o de problemas de salud mental. Cada uno reacciona de forma diferente ante situaciones estresantes. Son diferentes las reacciones típicas que ocurren cuando hay que refugiarse en sitio debido a un problema inmediato. Algunas de las emociones que podemos estar sintiendo ante esta situación incluyen la ansiedad, el miedo, la preocupación, le incertidumbre, la frustración, la tristeza, el aburrimiento, temor por pedida de ingresos o trabajo y efectos negativos en la habilidad de dormir bien y comer saludablemente.

El hecho de no poder continuar con la propia rutina es un factor que desorganiza nuestra estructura ya que perdemos la sensación de control. Es importante recordar la capacidad que tenemos para reorganizar una nueva estructura.

También podemos pasar por diferentes cambios incluyendo cambios en conducta como el aumento o disminución en sus niveles de energía y de actividad o la preocupación excesiva y hasta la incapacidad de sentir placer o divertirse. Cambios en su cuerpo como el dolor de estómago o dolores de cabeza u otras molestias o la pérdida o aumento de apetito; cambios en sus pensamientos como la dificultad para acordarse de cosas o el sentirse confundido. Todos estos síntomas pueden ser interpretados como excusas o razones para beber o usar drogas o para rendirse y no querer seguir adelante.

Si la locura de la adicción se vive en soledad durante sus últimas etapas, la recuperación siempre ocurre con la ayuda y la participación de otros. Y para eso necesitamos construir la resiliencia.

La Asociación Psicológica Americana (https://www.apa.org/topics/resilience) define resiliencia como ‘la adaptación ante la adversidad, el trauma, la tragedia, las amenazas o las fuentes importantes de estrés.’

El concepto de resiliencia ayuda a entender y promover el desarrollo positivo en situaciones percibidas originalmente como negativas y en retos potencialmente destructivos. Es la capacidad de responder a presiones y tragedias rápida, adaptativa y efectivamente, recordando y reconociendo dicha experiencia para enfrentar futuras adversidades. Aplicado a los seres humanos, la resiliencia es la capacidad que tiene un individuo de desarrollarse positivamente a pesar de las adversidades. Su objetivo es salir fortalecidos y transformados por la experiencia, por más dolorosa que pudiera resultar.

Podemos construir la resiliencia utilizando varias herramientas como enfocándonos en las propias fortalezas, en vez de las debilidades; actuando sobre las soluciones, y no sobre las causas del problema; sustituyendo la rigidez por la flexibilidad y reconociendo que el pasado no puede ser cambiado, pero que sí podemos aprender cómo está influenciando en nuestro presente para hacer hoy los ajustes convenientes.

Para quienes están en aislamiento social, la recomendación general es establecer una rutina con espacio para el ocio y el ejercicio; informarse por canales oficiales como el CDC (www.cdc.gov) y SAMHSA (www.samhsa.gov) y no sobreexponerse a las noticias sobre el coronavirus. También se recomienda mantener el contacto con familia y amigos. Es importante permanecer conectados a través de redes sociales, pero de nuevo, con límites. Los vínculos, aunque sean virtuales son el gran amortiguador del estrés.

Tenemos que confiar en nuestra recuperación. Lo que hemos logrado hasta hoy vale mucho y no debes olvidar todo lo que has hecho para realizarlo. Utiliza tus herramientas, solo porque no puedes salir no tienes que olvidarlas. Y para relajarnos, comience con cosas que sabes que te ayudan a relajarte, como el respirar profundo, meditar o rezar, o entretenerse con un pasatiempo que le agrade.

Haga cosas que disfruta, como leer, escuchar música, hacer ejercicio o darse un baño; hable sobre su experiencia y sus sentimientos con sus seres queridos y sus amigos; mantenga la esperanza y piense positivamente.

Y finalmente, si necesita ayuda, por favor búsquela. Hoy tenemos ayuda disponible y puedes visitar www.samhsa.gov donde encontraras teléfonos y sitios web de apoyo.

[Un seminario web de este mismo título está disponible en nuestra página en inglés, español y portugués. Por favor visite https://attcnetwork.org/centers/national-hispanic-and-latino-attc/home]


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Como o isolamento social, a solidão e a insegurança afetam as pessoas em recuperação de transtornos por uso de substâncias e distúrbios mentais durante o COVID-19; e o que fazer sobre isso

Por Pierluigi Mancini, Ph.D.
Diretor de Projeto, Centro Hispânico -Latino de Treinamento e Assistência Técnica em Abuso de Substâncias (NHL-ATTC)

Estamos passando por um período difícil, juntos, e todos estamos lidando com isso à nossa maneira. O que o COVID-19 nos causou como sociedade é traumático e o impacto de traumas não-tratados pode ser sútil, insidioso ou totalmente destrutivo.

A Associação Americana de Psiquiatria (APA) www.psychiatry.org relatou em uma pesquisa recente que quase metade dos americanos (48%) estão preocupados com a possibilidade de contrair o coronavírus, 40% estão preocupados em ficar gravemente doente ou morrer e 62% estão preocupados com a possibilidade de ter a família e os entes queridos infectados.

É natural sentir estresse, ansiedade, angústia e preocupação durante e após uma crise como o COVID-19. Cada pessoa reage de maneira diferente e os sentimentos mudam com o tempo. Você precisa se tornar consciente de como você se sente e aceitar.

A separação dos entes queridos, a perda da liberdade e a incerteza sobre o estado da doença são motivo de preocupação. Estudos começaram a mostrar que a maioria das pessoas que estão em isolamento social relata efeitos psicológicos negativos, incluindo sintomas de estresse pós-traumático, confusão e raiva. Os maiores estressores incluem o medo de infecção, receio de perder o emprego, frustração, tédio, suprimentos inadequados, informações inadequadas, perdas financeiras e estigma.

A falta de conexão pode causar uma sensação de solidão e é especialmente agravada naqueles que se recuperam de transtornos por uso de substâncias e distúrbios mentais. Cada um reage de maneira diferente a situações estressantes. As reações típicas que ocorrem quando existe a orientação de ficar em casa durante um determinado período, por conta de um problema imediato são diferentes. Algumas das emoções que podemos sentir nessa situação incluem ansiedade, medo, preocupação, incerteza, frustração, tristeza, tédio, medo de não ter renda ou trabalho e efeitos negativos na capacidade de dormir bem e comer de forma saudável.

O fato de não podermos continuar com a rotina em si é um fator que desorganiza nossa estrutura, pois perdemos a sensação de controle. É importante lembrar a habilidade que temos de reorganizar uma nova estrutura.

Também podemos passar por diferentes mudanças, incluindo mudanças no comportamento, como aumento ou diminuição dos níveis de energia e atividade, ou preocupação excessiva e até a incapacidade de sentir prazer ou se divertir.

Alterações no seu corpo, como dores de estômago, dores de cabeça, outros desconfortos ou perda ou aumento do apetite; mudanças nos pensamentos, como dificuldade em lembrar as coisas ou se sentir confuso. Todos esses sintomas podem ser interpretados como desculpas ou razões para beber ou usar drogas ou para desistir e não querer continuar.

Se a loucura por conta do uso de substâncias é vivida em solidão durante seus últimos estágios, a recuperação sempre ocorre com a ajuda e participação de outras pessoas. E para isso, precisamos construir resiliência.

A Associação Americana de Psiquiatria (https://www.apa.org/topics/resilience) define resiliência como "adaptação a adversidades, traumas, tragédias, ameaças ou principais fontes de estresse".

O conceito de resiliência ajuda a entender e promover o desenvolvimento positivo em situações originalmente identificadas como negativas e em desafios potencialmente destrutivos. É a capacidade de responder a pressões e tragédias de forma rápida, adaptativa e eficaz, lembrando e reconhecendo essa experiência para enfrentar adversidades futuras. Aplicada aos seres humanos, a resiliência é a capacidade de um indivíduo se desenvolver positivamente, apesar das adversidades. Seu objetivo é sair fortalecido e transformado pela experiência, por mais dolorosa que seja.

Podemos construir resiliência usando várias ferramentas como focar nos nossos pontos fortes, e não nas nossas fraquezas; atuar nas soluções, e não nas causas do problema; substituir rigidez por flexibilidade e reconhecer que o passado não pode ser mudado, mas que podemos aprender como ele está influenciando nosso presente para fazer os ajustes apropriados hoje.

Para quem está em isolamento social, a recomendação geral é estabelecer uma rotina com espaço para lazer e exercício; mantenha-se informado através de canais oficiais confiáveis como o CDC (www.cdc.gov) e SAMHSA (www.samhsa.gov) e não se exponha demais às notícias sobre o coronavírus. Também é recomendável manter contato com familiares e amigos. É importante manter-se conectado através da mídia social, mas novamente, com limites. As conexões, mesmo que sejam virtuais, são os grandes amortecedores do estresse.

Devemos confiar em nossa recuperação. O que alcançamos até agora é muito valioso e você não deve esquecer tudo o que fez para chegar até aqui. Use suas ferramentas, só porque você não pode sair, não precisa esquecê-las. E, para relaxar, comece com coisas que você sabe que te ajudam a relaxar, como respiração profunda, alongamento, meditação ou oração, ou mantendo-se ocupado com um hobby que você gosta.

Faça coisas que você goste, como ler, ouvir música, se exercitar ou tomar um banho; fale sobre sua experiência e sentimentos com entes queridos e amigos; mantenha a esperança e pense positivamente.

E, finalmente, se precisar de ajuda, encontre-a. Hoje temos ajuda disponível e você pode acessar www.samhsa.gov para encontrar telefones e sites de apoio.

[Um seminário com esse mesmo título está disponível em nossa página em inglês, espanhol e português. Por favor visite https://attcnetwork.org/centers/national-hispanic-and-latino-attc/home]

Great Lakes ATTC: Helping Build Recovery-Oriented Systems of Care


Implementation, the final phase of the ATTC Technology Transfer Model, moves an innovation into routine practice in real-world settings.

For the Great Lakes ATTC, implementing Recovery-Oriented Systems of Care in real-world settings has been a particular focus since the concept first began to take shape. (See related blog post: Building a Science of Recovery: The Pinnacle ATTC Achievement.)

SAMHSA defines a Recovery Oriented System of Care as:

“A coordinated network of community-based services and supports that is person-centered and builds on the strengths and resiliencies of individuals, families, and communities to achieve abstinence and improved health, wellness and quality of life for those with or at risk.” (SAMHSA, 2011)

The Recovery-Oriented Systems of Care Illinois State Network (ROSC-ISN)
The Great Lakes ATTC provides training and technical assistance for ROSC implementation projects throughout the six-state region at the state, county, and local levels. 

One example of a statewide initiative currently underway is the Recovery-Oriented Systems of Care Illinois Statewide Network (ROSC-ISN), launched by the Illinois DHS in the fall of 2018 under the leadership of Dani Kirby, director of Substance Use Prevention and Recovery (SUPR) at IDHS. Rex Alexander, also of IDHS SUPR, serves as the project director for ROSC-ISN.

“Our technical assistance has included all of the coordination, planning, and delivery for the ROSC-ISN,” says Scott Gatzke, Great Lakes TA coordinator for the project. “This includes face-to-face meetings, one-on-one coaching calls, monthly peer learning calls, and report-out sessions where participants share lessons learned.”

The goal of ROSC-ISN to help eight local ROSC Councils throughout the state build community-based recovery supports tailored to the unique needs of the community. Each ROSC Council has a lead agency that provides leadership for the local council, with support from IDHS/SUPR.

One of those lead agencies is the Chicago Recovery Communities Coalition, a peer-driven, peer-run Recovery Community Organization founded by Dora Dantzler-Wright.

“We are collaborating with organizations that provide substance use disorder services to identify service gaps,” explains Dantzler-Wright. “Being part of the ROSC-ISN has enabled us to reach over 13 communities on the west side of Chicago, provide information to those agencies, and collect data. This state initiative is helping our RCO to work on a system transformation.”

Adds Gatzke, “The ultimate goal of this project is to create multiple stand-alone Recovery Community Organizations in Illinois that will spin off from the ROSC Councils. The system change that emerges from this important initiative will provide valuable lessons that our Center can apply in other ROSC initiatives in our region and beyond.”

Mid-America ATTC: Creation of Intensive technical assistance manual for trauma informed care (TIC)


The Mid-America Addiction Technology Transfer Center (a collaboration between Truman Medical Center Behavioral Health and the University of Missouri-Kansas City School of Nursing and Health Studies) developed an intensive technical assistance manual to be used by Technology Transfer Centers to facilitate trauma informed care (TIC) implementation in substance use and recovery service settings.

The manual will provide guidance for TIC consulting teams on issues such as:

  • Evidence for effectiveness of TIC implementation, including improved client experience and employee well-being and retention
  • Key considerations for TTCs as they determine capacity and strategies to provide TIC consultation
  • Examples of different levels of TA activities to promote implementation
  • Core components of trauma-informed care and corresponding consultant and organization activities during each stage of implementation
  • Defining and navigating the role of a consultant in organizational change
  • Organizational assessment tools, meeting facilitation techniques, and approaches for developing strategies for change with leadership
  • Building and supporting organizational capacity to lead, sustain, and evaluate TIC implementation
  • Future considerations for TIC implementation may be developed for peer recovery coaches, CLAS standards, child welfare, and other community partners

To pilot the manual’s multi-faceted TIC implementation process, Mid-America conducted site visits to regional provider agencies expressing interest in becoming a TIC environment. Osawatomie State Hospital (OSH) in Kansas was selected as the initial pilot site; OSH leadership signed a memorandum of understanding committing the organization to weekly on-site and virtual engagements with TIC TA specialists. The OSH leadership and the TIC TA specialists will navigate through multiple steps including relationship building and program design, and movement through four stages: trauma aware, trauma sensitive, trauma responsive, and trauma informed.



Movement to a trauma informed culture requires dedication from all levels of staff, from the ground up and top down. With thorough self-evaluation through surveys and group discussions regarding individuals and the provider organization as a whole, the end goal is operating with a Trauma Informed Care lens. Once provider organizations have reached this stage, the aim is that the organization will:

  1. Have a mission statement, goals and/or objectives explicitly reference sustaining a Trauma Informed Care culture and environment;
  2. Demonstrate a sustainable commitment to trauma-informed values and all employees and volunteers implement trauma-informed practices;
  3. Other agencies and community partners turn to organization for expertise and leadership;
  4. All staff respond to internal and external changes, barriers, and growth through a Trauma Informed lens.
A secondary goal of the project is to field-test evaluation tools, resources, tips, case studies, and step-by-step guidance for TIC consultant teams. In 2021, Mid-America plans to initiate a virtual TTC TIC Team Learning Collaborative to provide initial guidance in how to use the intensive technical assistance manual and support those regional ATTCs providing TIC consultation.

For more information about Trauma Informed Care, please see the Mid-America ATTC’s website: https://attcnetwork.org/centers/mid-america-attc/implementing-trauma-informed-care-sud-treatment-and-recovery-settings

Learning from Crisis: PDSA in Times of Challenge



Mat Roosa, LCSW-R
NIATx Coach

Crisis requires that we triage the most urgent matters, and take rapid action to address them.
Crisis demands that we limit our analysis to the critical data points.
Crisis demands that we try new and untested strategies, and rapidly respond to the results of our efforts.

Crisis is dangerous, chaotic, messy, heart-wrenchingly painful,…and also an opportunity for invention.

During the past several weeks you probably have:
  1. Recognized immediate problems.
  2. Prioritized resources.
  3. Taken rapid action to test new strategies.
  4. Made decisions based on key data.
  5. Learned a lot from testing these new strategies and refined your efforts.
Put another way, you have been working your way through a challenging crisis using Plan-Do-Study-Act change cycles.

Rapid-cycle Testing: One of the Five NIATx Principles
“The fifth principle of the NIATx model is what we call rapid-cycle testing. Structured around what’s known as the PDSA (Plan-Do-Study-Act) Cycle, rapid-cycle testing is used to quickly evaluate the impact of potential changes on a given aim. In rapid-cycle testing, the executive sponsor, change leader, or team comes up with ideas for changes to test, and then tests each of those changes in quick succession for a short time on a limited test pool. During each test (a.k.a. PDSA Cycle), the team collects and analyzes data relevant to its chosen aim to determine whether the change has produced a desirable effect on performance levels. Depending on the outcome of that analysis, the team may decide to abandon the change completely and begin testing an entirely new change; adapt the change for further improvement and retest the modified version; or adopt the change, testing it again on a slightly larger scale, or in conjunction with other changes that have already proven successful in testing. In any case, the team uses the knowledge it has gained from one testing cycle to improve subsequent cycles. A new procedure is only implemented on a full scale once it has been proven in testing to yield significant improvement in regard to the project’s aim.”

From The NIATx Model: Process Improvement for Behavioral Health

See related blog post: Make it Quick: NIATx Principle #5

A Perfect Time for Rapid Change

A crisis like the one we are all facing right now is tailor-made for rapid-cycle PDSA change. Many of us have been using the NIATx model—perhaps without even knowing it. Right now is an excellent time to document the PDSA cycles that you have been conducting.

A few questions may help you to refine your understanding of the crisis work that you have been doing, and to document your PDSA efforts.
  • What did you observe through data or experience?
  • What did you do in response?
  • What was the result?
  • What did you learn?
You might also want to use the NIATx Change Project Form to document your recent efforts retrospectively. You can find the form and step-by-step instructions on how to conduct a PDSA Cycle on the NIATx website.

As this crisis persists, we struggle to figure it out as we go. Finding the opportunity in this unprecedented challenge is both difficult and painful. Yet, one way to find purpose and meaning moving forward is to learn everything we can from it.

Consider how rapid-cycle PDSA can teach you more about what you have done and will do, as we work our way through this together.


About our Guest Blogger
Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development, and planning, evidence-based practice implementation. He also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at matroosa@gmail.com


The World in our Hearts: A Message from the ATTC and NIATx Networks

Contributed by the Southeast ATTC
Dawn Tyus, Director
Pamela Woll, Product and Curriculum Development Consultant


Greetings from the makeshift offices we’ve set up in our kitchens and basements and spare bedrooms. The world outside our windows looks like a normal, pretty Spring day, but the world that lives in our hearts is going through some strange, difficult times.

We’re grateful to be able to continue to serve you from our remote outposts, but something important is missing: you. We used to be able to catch up with you at conferences, before and after sessions, and at technical assistance visits. We’re happy whenever we see your little video tile on our Zoom screens, but it doesn’t tell us how you’re doing.

In this field—this culture, really—that has dedicated our lives to the well-being, resilience, and recovery of people with substance use disorders (SUD), you’re probably carrying an extra weight in your heart. We know these times are particularly hard on people whose lives have left them wounded. For people whose SUDs are active, and people whose wounds are still raw in recovery, alcohol and drugs can look like part of the solution, rather than the big flashing hazards they really are.

If you’re a counselor, a coach, a supervisor, an administrator, or any other member of this field, you’ve probably read it in the literature and proved it in your work and your lives: The most healing thing we have going as a field is caring, trustworthy human connection with people. Pandemic disease may be the cruelest kind of disaster, because it robs us of that in-person, face-to-face human connection.

But there’s something we must never forget: This virus may be young and clever and highly contagious, but we have a lot of things it doesn’t have.

  • We have love—for our families and friends, for our colleagues, for our communities, for the people we serve, and for the work we do.
  • We have faith—in recovery, in our values, in our higher powers, in our science, in our skills, and in ourselves.
  • We have a field that has fought its way through loss and pain and stigma and discrimination, to bring real, lasting recovery to people who were once laid low by an illness that has killed far more people than any virus.
  • We have the memory of every time we watched someone make that transition into recovery—and saw a human life transformed before our eyes.
  • And we have the internet—for all the problems it sometimes causes, still a great tool for connection. We can use it to reach out, listen, teach, witness people’s pain, walk alongside them, and BE THERE—for them and with them.
And so, we’re learning to connect, more and more effectively, across the space between us. The many Centers in the ATTC and NIATx Networks have increased our use of face-to-face technologies and our development of resources to help agencies and individuals find the help, guidance, and education they need to stay informed, resilient, and effective in promoting wellness, health, and recovery.

The ATTC Network’s excellent webinar series on Telehealth is only one of many resources on the Network’s trove of Pandemic Response Resources (https://attcnetwork.org/centers/global-attc/pandemic-response-resources-responding-covid-19), and there has never been a better time to dip into the many free e-learning courses available through Health-eKnowledge.

So, we have a lot to say, but something is missing. In this strange, sad, and sometimes heroic world we’re living in, we’d like to hear what you’re going through. We want to know what we can do to help you survive, thrive, and come out of this difficult time stronger, more resilient, and more inspired. Please reach out to us.

We are here for you. We are dedicated to you and the people you serve. We want to connect with you—and help you connect with others—so we can all get each other through this time.

We believe in you. We’ve seen the enormous strengths you bring to your life and your work. We’ve seen the great love that drives you to keep going, even though it’s hard and it sometimes breaks your heart.

Please stay safe and healthy. Please stay connected. And, whatever fears and losses you’re carrying, please know that we hold you in our hearts.




About the Authors:

Dawn Tyus

Dawn Tyus is the Director of the Southeast Addiction Technology Transfer Center (SATTC) at Morehouse School of Medicine, located in Atlanta, Georgia. Dawn has been affiliated with Morehouse School of Medicine and SATTC for eleven years, as a Project Consultant, and was promoted to lead the team as the Project Director in 2011. As Director of ATTC, Dawn is responsible for the management, growth, and business development activities of the project, manage the day-to-day operations including implementation of the policies and programs, responsible for the professional development of staff, as well as new and innovative programs, manage approximately 10 external and internal staff members and consultants, facilitate professional development trainings for clinicians and staff, interface with collaborative partners and stakeholders on a local, federal and state level to organize strategies for statewide initiatives.

Dawn actively work with faith communities to strengthen their awareness, and build their skill set on working with individuals with mental health and substance use disorders.

Dawn is a member of ATTC CLAS Standards and Pre-Service Education Workgroup, Dawn is currently on the board of the Georgia School of Addiction Studies, and the Advisory Board for the Clark Atlanta University’s HBCU C.A. R. E. S.

Dawn has an impressive background in which she brings a wealth of experience from various perspectives. Her background spans many disciplines which include: nonprofit organizations, government, corporate, counseling services, consulting, strategic planning, group and individual coaching She received a Bachelor’s degree in Criminal Justice, and a Masters of Education degree in Community Counseling from Mercer University, and is currently completing her Doctoral degree in Counseling Studies at Capella University. Dawn is also a Licensed Professional Counselor in, the State of Georgia where she provides family, individual, and group mental health therapy.

Pamela Woll
Pamela Woll, MA, CADP is a Chicago-based author, curriculum developer, and consultant dedicated to increasing the resilience and capacity of individuals, families, communities, organizations, and systems of care. Her primary areas of focus include trauma-informed and recovery-oriented systems and services; the physiology/neurobiology of resilience, stress, and trauma; public health approaches to behavioral health and wellness; elimination of health and socioeconomic disparities; and the strengths and needs of service members, veterans, and their families. Her recent publications include Compassion Doesn’t Make You Tired: Unmasking and Addressing “Compassion Fatigue”; Addressing Stress and Trauma in Recovery-oriented Systems and Communities, and You Fit Together: Body, Mind, Resilience and Recovery, all published in 2017 by the ATTC Network Coordination Office. Many of the materials she has written are available for free download from her web site, https://sites.google.com/site/humanprioritiesorg/.

Traditional Ways of Sharing Modern Knowledge: Peer-to-Peer Learning Communities

Jeff Ledolter Program Manager of the Tribal Opioid Response TA ProgramNational American Indian and Alaska Native ATTC

Image posted with permission of all participants. 

In February 2020, the National American Indian and Alaska Native ATTC hosted a regional technical assistance meeting in Oklahoma City for recipients of the Tribal Opioid Response grant. It was similar to meetings we had held in other regions. Doctors, nurses, grant managers, counselors, and other health professionals from 15 tribal health clinics in the surrounding states came together in a hotel conference room to talk about a common sickness in their comm­­unities: opioid use disorder.

We began each of the three days normally, that is, in a good way. Each morning, a tribal elder native to the region welcomed participants with a brief invocation, or song, or smudge. We explained the services we offered, along with our partners at the Association of American Indian Physicians, whose headquarters was just down the street. Speakers were scheduled over the two and a half days to cover topics ranging from presentations on stigma to telehealth demonstrations, but most of the time was reserved for the attendees to speak and share their experiences.

Hosting this meeting as a non-native, it was crucial to consider the culture of the communities and the indigenous strategies that they have developed over generations to address communal issues. Acting with cultural humility establishes trust and buy-in from the community and lets them factor in their existing strategies. It’s also important to engage for a long period. Providing TA means making a commitment and thinking about strategies that will work for the long term. Community-based, tribally-based participatory programming is essential to actually affecting change that will last. Our role is not to direct tribes how to act of what to do, but to meet them where they are at, provide them with the best, most up-to-date knowledge that we can and work with them to find solutions relevant to their people and that reflect their wealth of indigenous knowledge.

After brief introductions, representatives began sharing their stories. As we started, the magnitude of the problem facing us was palpable. Each person understood the threat that opioid use disorder posed to their community, and this showed in their presentations. This had touched their families and neighbors, and threatened to cut the bonds that united them as a tribe. They explained the goals they had for their communities, as well as the barriers: lack of community buy-in, stigma towards medication-assisted treatment (MAT), staff turnover and burnout. But as these representatives shared their experiences, their tone became more confident and enthusiastic. As these professionals explained how they thought they had been facing these problems alone, they saw how many others were experiencing the same thing.

One attendee m­entioned their difficulty filling beds in their treatment facilities. Another immediately asked if they could send patients from their neighboring state, and they traded information. One attendee from an Oklahoma tribe explained how they developed a prevention program for native youth by forming traditional stickball leagues. Another explained how patients were denied services because they didn’t have official identification, so they partnered with local recovery centers to hold “ID Expos,” where donated funds would be used to pay for issuing acceptable documentation. They explained that in 18 months they created over 1000 IDs, prompting a flurry of questions from the audience.

As one representative put it: “This training lacked the underlying fear of failure, desire to ‘one-up’ everyone, pride, tendency to exaggerate credentials and success of programs, and relationship hesitancy. It was so refreshing to hear humility, openness about struggle and challenges, see the desire to learn new info and personal engagement between participants.”

Often when presented with overwhelming challenges, it is easy to become discouraged and give up. But even in modern times, tribes can gain strength from a resource they have relied on for generations: each other. The opposite of addiction is not sobriety, but connection.

To see a collection of TOR resources that our ATTC has prepared, please visit our website at: https://attcnetwork.org/centers/national-american-indian-and-alaska-native-attc/tor-resource-page

For more information on our center’s programs and events, visit https://attcnetwork.org/centers/national-american-indian-and-alaska-native-attc/home or email Jeff Ledolter at jeff-ledolter@uiowa.edu.

DEBUNKED Podcast launched to Debunk Myths about Harm Reduction



By Dr. Sandra H. Sulzer


The Tribal and Rural Opioid Initiative of Utah State University has launched a podcast to debunk myths around harm reduction. The first two episodes are already released with a pending special episode on COVID-19 myths in production.

While harm reduction strategies such as syringe distribution and naloxone education are the gold standard best practices recommended by the CDC, NIH and NIDA, there is still substantial resistance toward these methods, sometimes even amongst providers. There is evidence that abstinence-only treatment strategies are sometimes perceived to be morally superior, regardless of the evidence base. Harmful beliefs about Medication Assisted Treatment (MAT) prevent some health providers from offering the best healthcare possible, and it may deter family members and others in support networks from offering needed support to persons who are in recovery and utilizing these services. For example, some people who have used or still use drugs have criminal convictions and may have lost their driver’s license. In those cases, it can be the difference between relapse and recovery to have a family member or friend willing to help provide transportation to a methadone clinic or needed appointments. When there is general stigma toward MAT, and people hold beliefs such as “you are substituting one drug for another,” fewer people get access to needed care. DEBUNKED works to openly talk about myths like this one in order to change beliefs around harm reduction best practices.

Our podcast is based on a systematic review of 99 articles related to effective stigma reduction around addiction treatment services. We also draw from two curricula we have designed that provide continuing education credits to substance use disorder counselors as well as naloxone training to community members that have both show statistically significant reductions in stigmatizing beliefs. Every DEBUNKED episode is planned and curated by an editorial board that includes persons in recovery or who use drugs, affected family members, public health experts and research scientists in partnership with Utah Public Radio. This program is funded by the Substance Abuse and Mental Health Services Rural Opioid Technical Assistance grant with additional support provided by Regence Blue Cross Blue Shield. The Tribal and Rural Opioid Initiative also receives support from The U.S. Department of Agriculture, National Institute on Food and Agriculture Rural Health and Safety Education funding.

You can learn more about our Tribal and Rural Opioid Initiative efforts at http://khs.usu.edu/outreach/troi and you can access our DEBUNKED podcast and promotional video from http://khs.usu.edu/outreach/debunked, or check out @DebunkedPod on Twitter, Instagram and Facebook.


Sandra Sulzer Bio:
Dr. Sandra Sulzer oversees the DEBUNKED podcast as the Director of the Office of Health Equity and Community Engagement and the Tribal & Rural Opioid Initiative. She has a PhD in Sociology and, Community and Environmental Sociology from the University of Wisconsin-Madison with a specialization in medical sociology and social psychology. She completed a health services research postdoc at the University of North Carolina- Chapel Hill, Cecil G. Sheps Center for Health Services Research and an integrative medicine postdoc at the University of Wisconsin-Madison, Department of Family Medicine and Community Health. She is faculty in the Masters of Public Health program at Utah State University where she teaches Public Health Communication and Holistic Health.

Using Text Messages to Improve Substance Use Disorders Treatment Outcomes


Nancy Roget, MS, MFT, LADC
Co-Director, Mountain Plains ATTC


Annually, the Substance Abuse Mental Health Services Administration (SAMHSA) conducts a survey called the National Survey on Drug Use and Health (NSDUH). This survey interviews almost 68,000 individuals across the nation regarding their use of alcohol, prescribed medications, and illicit drugs. In 2019, the NSDUH survey found that almost 20 million individuals over the age of 18 had a substance use disorder (SUD), with less than 10% of these 20 million receiving treatment services. To address this vast treatment gap between individuals who report having a SUD and those that enter treatment, both researchers and policy-makers advocated for strategies that increase access to treatment services, promote low-cost resources, and offer engagement activities. An innovative response suggests that behavioral health technologies may offer one solution.

According to Ashford and colleagues (2018), in the last decade the use of technology by
SUD treatment and recovery support providers has helped increase the reach of their services, lower the threshold for patient engagement (e.g., made it easier for patients to enter treatment or recovery support services) and offer services that serve as an adjunct or complement to treatment and recovery services (p.19). At the same time, the use of technology (e.g., mobile phone, smart phone, tablet, computer, and internet) has increased in the general public. Recent data from Pew (2019) found that 81% of adults owned a smartphone, which was up 4% from 2018, and 73% had high speed internet at home. Smartphone use has increased among SUD treatment populations as well, with smartphone ownership ranging from 57% to 80% (Ashford et al., 2018; Dahne & Lejuez, 2015; Milward et al., 2015; Winstanley et al., 2018). These reported smartphone ownership rates for individuals involved with SUD treatment services have increased dramatically from an initial study done in 2013. Mobile phone ownership for this population increased substantially as well, ranging between 83% and 95%. Access to the internet is still low for the SUD treatment population but most individuals reported accessing internet services through their phones rather than home broadband. The bottom line as highlighted in the above-mentioned studies is that most patients have access to a mobile phone that can be used to receive or send text messages and/or to access the internet. Finally, a recent study (Ashford et al., 2018) showed that individuals in SUD treatment expressed a strong interest in using digital resources to manage and monitor their recovery, which included their preference to use an app on their phone or receive text messages. 

In light of these recent findings on technology use and patient feasibility/interest data, the Mountain
Plains ATTC worked with Dr. Scott Walters, a noted professor, National Institute on Drug Abuse (NIDA) researcher, and psychologist to develop a series of products and training/technical assistance activities. These products and activities were created for treatment and recovery support providers on how to create and implement one-way short message service (SMS) text messaging. The goal of implementing this innovation was to increase patient/peer engagement aligning with services like groups/individual sessions. A text messaging curriculum was created by Dr. Walters and piloted by the Mountain Plains ATTC in a two-part webinar series in Spring 2019, after which revisions were made to the manual and webinars, and a text messaging poster created that reminds providers and peers about texting language and tips. In August 2019, the webinar series was facilitated again, recorded, and posted in the products section on the Mountain Plains ATTC website along with the poster and manual. In November 2019, a small four-week intensive technical assistance (ITA) pilot was implemented with six SUD treatment providers located in Region 8 to assist with the implementation of text messaging within one of their treatment/recovery support components. Currently, these six providers are participating in the last part of the ITA project that includes individualized consultation sessions with Dr. Walters to assist with implementation issues. Results from this ITA project will be posted under a ‘lessons learned’ document. Initial feedback from participants reflects the principles of technology transfer that the innovation was easy to use, met a need at the agency, and enhanced their current service delivery. A recent Norwegian study by (Bjerke et al., 2009) on the use of text messaging found that patients felt a greater sense of connectedness to the providers through the use of text messaging. The Mountain Plains ATTC staff hopes the providers involved in this project receive similar patient feedback.

References
Ashford, D. R., Lynch, K., & Curtis, B. (2018). Technology and social media use among patients enrolled in outpatient addiction treatment programs: Cross-sectional survey study. Journal of Medical Internet Research, 20(3), e84. http://dx.doi.org/10.2196/jmir.9172.

Bergman, B. G., Greene, M. C., Hoeppner, B., & Kelly, J. (2018). Expanding the reach of alcohol and other drug services: Prevalence and correlates of US adult engagement with online technology to address substance problems. Addictive Behaviors, 87, 74–81. https://doi.org/10.1016/j.addbeh.2018.06.018.

Bjerke, T. & Kummervold, P., Christiansen, E. & Hjortdahl, P. (2009). “It made me feel connected”—An exploratory study on the use of mobile SMS in follow-up care for substance abusers. Journal of Addictions Nursing, 19, 195-200. 10.1080/10884600802504735.

Bliuc, A. M., Best, D., Iqbal, M., & Upton, K. (2017). Building addiction recovery capital through online participation in a recovery community. Social Science & Medicine, 193, 110–117. https://doi.org/10.1016/j.socscimed.2017.09.050.

Dahne, J. & Lejuez, C. (2015). Smartphone and mobile application utilization prior to and following treatment among individuals enrolled in residential substance use treatment. Journal of Substance Abuse Treatment, 58(Supplement C), 95–99. https://doi.org/10.1016/j.jsat.2015.06.017.

Masson, C. L., Chen, I. Q., Levine, J. A., Shopshire, M. S., & Sorensen, J. L. (2018). Health-related internet use among opioid treatment patients. Addictive Behaviors Reports, 9, 100157. doi:10.1016/j.abrep.2018.100157

Milward, J., Day, E., Strang, J., & Lynskey, M. (2015). Mobile phone ownership, usage and readiness to use by patients in drug treatment. Drug and Alcohol Dependence, 146(Supplement C), 111–115. https://doi.org/10.1016/j.drugalcdep.2014.11.001.

Pew Research Center (2019). Mobile Technology and Home Broadband 2019. Accessed January 2020 from https://www.pewresearch.org/internet/2019/06/13/mobile-technology-and-home-broadband-2019/.

Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/.

Winstanley, E. L., Stroup-Menge, B., & Snyder, K. (2018). The promise of technology-based services for addiction treatment clients residing in nonurban areas. Journal of Studies on Alcohol and Drugs, 79(3), 503–504.

Changing Practice Through Collaboration, Art, and Science



Respectfully submitted by Holly R. Ireland, LCSW-C


The Central East ATTC serving Health and Human Reserves Region 3 has been managed by the Danya Institute for nearly 20 years. Danya’s tagline is “Changing Communities Through Changing Practice” and collaboration has always been a central core value to our work. Workforce development and capacity building changes in practice could not be successfully sustained without collaboration. The mutual exchange of perspectives, ideas, and investment leads to richer and more lasting changes for systems, organizations, professionals and most importantly the individuals and families receiving behavioral healthcare. From it emerges the necessary innovation to keep pace with rapidly evolving trends, leading to a responsive and adaptive system of care.

In recent years there has been an emerging "science of collaboration."[1] This involves intentional efforts to measure the process of learning what works and what doesn't, then use data-informed decision making to improve how leaders design, manage, and evaluate collaboration projects. The process helps to educate and train future leaders with the necessary organizational and managerial skills in collaboration. Literature about the science of collaboration emerged historically in the science sector but is increasingly found in the health and behavioral health sectors.


Given Danya’s core value and the SAMHSA imperative to accelerate the adoption of evidence-based practices in behavioral health through intensive technical assistance (TA) to organizations, localities, and systems; the Central East ATTC has implemented several intensive TA capacity building collaborative projects in organizations, municipalities, counties, and statewide and regional systems of care. Stakeholder collaborations involving three or more entities or organizations have been central to implement capacity building projects in the adoption of evidence-based practices in Motivational Interviewing (MI) and Screening, Brief Intervention, and Referral to Treatment (SBIRT).



In Year 1, the Mount Rogers Community Services Board (MRCS)[2] in Wytheville, VA, collaborated with the Central East ATTC to increase Motivational Interviewing (MI) capacity. MRCS offers “a wide array of community services for individuals with mental health, intellectual and developmental disabilities, and substance use disorders. All services include the use of person-centered planning and embrace concepts of self-determination, empowerment, and recovery as core principles in supporting individuals to achieve their highest possible level of participation in work, relationships, and all aspects of community life.”[3] Candace Coffin, Director of Specialty Services –
Administration/Training, was the champion and internal facilitator of this project. The Central East ATTC engaged Christine Higgins, MINT Trainer, subject matter expert and external facilitator, to plan and implement this project. As part of the planning process, 20 staff members, mostly clinical supervisors, were identified and engaged as key collaborators and future MI trainers.



In Year 2, the project was launched in November 2018 and concluded in September 2019. It began with an MRCS Senior Leadership dinner meeting, which provided an overview of the 6-9 month project; and included two (2) back-to-back, one-day MI Basic training events on November 1 and 2, training 72 staff members. Christine returned to Wytheville in December 2019 to provide MI intermediate training to 24 staff members and clinical supervision of MI training to 22 supervisors.

From December through March, there were several virtual TA sessions with Chrisitine and the 22 supervisors, both group and individually, that involved video recording, coding and feedback, as well as coaching in the supervision of MI. To enhance relationship building, engagement and collaboration for the in-person and virtual sessions between Christine and the trainees, Candace created name placards with photos.

In March 2019, Christine provided MI Advanced to 14 of the supervisors, and 20 of them participated in an MI Training of Trainers in April 2019.

From April through September 2019, Christine provided an additional 20 hours of virtual TA to support the training plan development and implementation, as well as additional coaching in clinical supervision.

The MRCS MI Spirit Committee was formed to ensure full integration of MI in the onboarding of new staff, training of the existing 700+ staff members, and maintenance of a robust commitment to the spirit of MI throughout the work of the organization.

“We are so deeply grateful to the [Central East ATTC] for all the training – well worth it. Our trainers are ready and Christine has been a huge support.” - Candace Coffin.

MRCS continues to contract with Christine Higgins directly for the development of 15 minute video to show at new employee orientations to introduce Motivational Interviewing. They also have a monthly training calendar for two-day MI training sessions from March through December 2020. The MI Spirit is strong at MRCS and the change in practice will endure.











[1] http://news.mit.edu/2013/the-science-of-collaboration


[2] http://www.mtrogerscsb.com/


[3] https://www.bbb.org/us/va/wytheville/profile/mental-health-services/mount-rogers-csb-0613-90006708#overview