AIMS:Telehealth and peer navigation are feasible strategies for connecting women in the criminal-legal system with medications for opioid use disorder (MOUD), yet implementation costs are not well understood. This study conducted a microcosting analysis of two interventions for women leaving jail in Kentucky: pre-release, PreTreatment Telehealth with a MOUD provider (TH-Only) and PreTreatment Telehealth combined with peer navigation (TH+PN) through the Justice Community Opioid Innovation Network (JCOIN). METHODS:From the provider perspective, we estimated total start-up costs, total intervention costs, and average cost per participant. Women participating in the clinical trial were randomly assigned to TH-Only (n=299) or TH+PN (n=301). Start-up costs were incurred primarily in 2019 - 2020; intervention costs represent expenses in 2021 - 2023. Cost data were collected from study and agency financial records and interviews with research staff and analyzed using Microsoft Excel (version 16.90.2). RESULTS:Start-up costs were $36,320, comprising planning, meetings, travel, and supplies. The total cost of TH-Only was $60,767, representing 259 telehealth sessions with an average duration of 47 minutes. Total cost of TH+PN was $472,148 based on 270 telehealth sessions (48 minutes), 268 peer navigation (PN) sessions (30 minutes), and 12 weeks of PN support post-release per participant. Average cost per TH-Only participant was $235 and per TH+PN participant was $1,760. CONCLUSIONS:Telehealth may be a relatively low-cost approach for jails lacking on-site MOUD services. Although more costly, combining telehealth with PN may add value by supporting service continuity and facilitating linkage to treatment during the jail to community transition.

Medications for opioid use disorder (MOUD) have been proven to be the most effective method for treating individuals with opioid use disorder (OUD). Individuals who are retained on methadone and buprenorphine treatment have a decreased risk of mortality when compared to others with OUD. However, many individuals in need of MOUD face transportation barriers that prevent them from having the requisite access to treatment. As part of the evidence-based practices (EBPs) implemented throughout the HEALing (Helping to End Addiction Long-term®) Communities Study (HCS), strategies to reduce transportation barriers to receiving methadone and buprenorphine at partner organizations were identified and implemented. Multiple strategies were employed including transportation agency contracts, bus passes, rideshare services, leased agency vans, and fuel cards. This study provides a description of the number of unique riders, including demographic and geographic characteristics, and the costs of providing these transportation services across participating counties. Throughout 2023, we partnered with thirty agencies across eight counties to administer 437,481.69 in transportation support services to 7,923 individuals. These services were distributed primarily to individuals who were white (81.8

INTRODUCTION:Peer recovery support services (PRSS) provided by Recovery Community Centers (RCC) address critical needs for individuals navigating the recovery process. Limited literature exists on the costs of providing these services for individuals with Opioid Use Disorder (OUD). The goal of this study is to identify and cost services for two separate PRSS programs provided by a Kentucky RCC, Voices of Hope-Lexington (VOH). METHODS:The study evaluated two models: VOH RCC standard services and an expanded PRSS program, designed to promote MOUD linkage and retention as a core intervention for a federal grant. We collected 2022 financial data from the agency and administered key informant surveys to determine how VOH staff spent their time. The study entered results into a modified Substance Abuse Services Cost Analysis Program (SASCAP) to calculate program costs and estimate average labor costs per week for PRSS and administration. RESULTS:The RCC standard program enrolled 721 individuals over the course of the year and incurred operating costs of $876,831. A large portion of RCC expenses ($201,671) were dedicated to community support services for daily walk-ins, such as mutual aid meetings, laundry, computer access, and community meals. Administration (46 %) also drove labor expenses. Annual per-participant costs were $2824. The Expanded PRSS program spent $2,500,613 on operations to serve 1411 individuals., Labor accounted for more than two-thirds of costs and the annual per-participant expenses were $5286. Allocations for administrative tasks comprised 20 % of expenses in the expanded PRSS program. The expanded PRSS program also invested heavily into barrier relief services, which was the second largest category for labor expenses among participant-facing services, representing a broad range of needs. CONCLUSIONS:Within the VOH RCC, labor is the primary driver of costs for both PRSS programs. Administrative expenses were high within the standard RCC program since future funding is uncertain. Federally sponsored research funding provided expanded PRSS services for individuals with OUD and allowed for barrier relief support such as transportation and housing. These services were identified as important tools to linking and retaining individuals in treatment beyond the standard RCC provided services.

The purpose of this study was to estimate the costs of starting up diverse interventions for preventing opioid misuse in young people aged 15 to 30. Interventions were to be delivered in the context of research trials funded under the National Institutes of Health HEAL (Helping to End Addiction Long-term®) Prevention Initiative. Start-up activities were conducted in systems and settings across the United States from 2019 to 2023. Start-up costs were estimated using activity-based costing from a provider perspective and common methods and data collection procedures across projects (n = 8). Descriptive statistics were used to understand the magnitude of and variability in start-up costs, cost drivers, and staff time. Factors explaining variability were identified from project activity descriptions. Start-up activities cost 37,541 on average, and33,492 at the median (2020 USD). Labor drove costs (89

Globally, harm reduction vending machines (HRVMs) have been used for decades to dispense safe injection equipment and other supplies to people who use drugs (PWUD). However, HRVMs have only recently scaled up in the U.S. and few operate in rural settings. This study describes preferences for HRVM design among rural PWUD in two Appalachian Kentucky communities. Peer-referral and outreach were used to recruit participants (n=731). Eligibility criteria were ≥18 years, residing in the target counties, and having used any drug (excluding alcohol, cannabis, and tobacco) to get high within 6 months. Interviewer-administered questionnaires elicited data on behavioral/demographic characteristics and HRVM design preferences. Sample characteristics and site-level differences were estimated accounting for peer-referral chain clustering. Naloxone was the most desired supply (95.6%), followed by syringes (94.5%) and fentanyl test strips (83.7%). Supplies for basic needs were popular, including water (82.6%), food (72.8%), and personal care kits (71.3%). The most endorsed location was the health department (71.1%). More than twice the number of participants wanted HRVMs installed outdoors (52.3%) rather than indoors (19.6%), but for 25.4%, indoor/outdoor installation preference varies depending on the venue. While over three-quarters reported that a surveillance camera would not affect their HRVM use, a substantial minority indicated it would be a deterrent, highlighting a key consideration for implementation. There were significant differences in supply and location preferences across the two communities. HRVMs may expand harm reduction service access in rural settings, but PWUD input is needed to ensure that their design responds to community needs.Clinical trials registrationNCT05657106

Objective: This pilot sequential multiple assignment randomized trial estimated the feasibility, acceptability, and scalability of telehealth motivational enhancement interventions for optimizing HIV prevention efforts in sexual minority men (SMM) who use stimulants. Method: Seventy SMM who use stimulants with nonreactive HIV results that were not taking preexposure prophylaxis (PrEP) were randomized to: (a) a two-session motivational interviewing (MI) intervention focusing on PrEP use and concomitant risk behaviors; or (b) a contingency management (CM) intervention with financial incentives for PrEP clinical evaluation ($50) and filling a PrEP prescription ($50). After 3 months, participants who reported they had not filled a prescription for PrEP were randomized a second time to: (a) switch to a second-stage intervention (i.e., MI + CM); or (b) continue with assessments only. Results: There was a robust engagement in the interventions, which participants described as flexible and nonjudgmental. Participants reported using CM incentives to meet basic needs and indicated that MI sessions improved their understanding of PrEP. The estimated cost of intervention delivery per participant was $404 for MI, $236 for CM, and $475 for MI + CM. Across both randomizations, participants who received CM only were most likely to provide verified evidence of PrEP use over 6 months, and there were potential benefits for reducing concomitant risk behaviors in nonresponders receiving MI + CM. Prior PrEP use and increases in PrEP intentions were significantly associated with verified PrEP use. Conclusion: Although more definitive trials are needed to examine effectiveness, telehealth motivational enhancement interventions are promising, scalable approaches for optimizing HIV prevention among SMM who use stimulants.

BACKGROUND:In 2018 Massachusetts mandated that county jails offer all FDA-approved medications for opioid use disorder (MOUD) to incarcerated individuals with OUD. Estimating costs needed to implement and sustain an MOUD program are not clearly known in jail facilities. The objective of this study was to identify the type of MOUD model deployed by the jails serving as research sites for the Massachusetts JCOIN hub, determine which resources were utilized at each stage of development, and estimate the associated costs. METHODS:Resources required to implement and sustain the MOUD programs were identified through detailed, site-specific microcosting analyses at six participating jails in Massachusetts. Quantitative resource utilization data were captured primarily through in-person site-visits and semi-structured interviews with key personnel. Unit costs were derived from the Federal Supply Schedule and Bureau Labor of Statistics from a site-specific level perspective. Our customizable budget impact tool, designed to assist jails/prisons with assessing the viability of alternative MOUD models, was used to organize each site's resources and estimate their associated costs. Resources/costs were summarized by site, according to type and phase, and cross-site comparisons were made to identify common program elements and unique models. RESULTS:Three MOUD models were identified. Model 1 consisted of a vendor hired to deliver and administer methadone daily, while clinical jail staff administered buprenorphine and extended-release naltrexone. Model 2 included facilities that hired a certified vendor to operate an in-house opioid treatment program (OTP) to oversee the administration of all MOUD. Jails in Model 3 became certified OTPs, thereby allowing jail staff to manage all aspects of the MOUD program. There was considerable variability in implementation costs, both within and across models, driven by model-specific factors, but also with switching models, expanding infrastructure, etc. Entering the sustainment phase, the per-person costs of care were quite similar across models but differed according to the proportion of costs considered time-dependent vs. variable. CONCLUSION:Our findings represent the most detailed and comprehensive estimates of resource/cost requirements for jail-based MOUD programs. Given the budget constraints faced by jails, the investment required to implement/sustain an MOUD program will likely result in the need to obtain additional funding or reallocate existing resources away from other initiatives.

Introduction Implementation of integrated strategies for improving access to behavioral health services for youth in the legal system requires evidence of the costs of changing existing practices, and stakeholders need to be aware of what types of investments (e.g., personnel, data systems) lead to more efficient implementation and better outcomes. Methods A cost analysis was conducted alongside the Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), a research cooperative comprising 34 community supervision agencies in seven states that were randomly assigned to Core or Core+Enhanced implementation interventions. Both were focused on improving screening, referral, and linkage to behavioral health services for youth with substance use disorders (SUD). Cost data were collected prospectively across all implementation phases. Results During Baseline, the average cost was $11,083 per site (range: $1104 to $19,399). Enhanced sites had relatively higher baseline costs ($13,176 vs. $9222 in the Core sites). During the Experiment phase, Enhanced sites continued to incur higher implementation costs relative to the Core sites, but these costs steadily declined and ultimately converged with Core sites as they entered the sustainment phase. Conclusions Enhanced sites had higher implementation costs; but both Enhanced and Core sites showed similar trends in decreasing costs across the Experiment period. These decreasing costs reflected both fewer meetings and lower participation over time. In a funding climate where available resources are already scarce, access to cost data can help agencies prepare to implement and sustain new practices.

US construction workers (CWs) have the highest cigarette smoking rate among all occupations (27.2% vs. 15%), yet the lowest coverage of workplace smoking cessation services (14% vs. 29%). This study aims to empower safety managers to implement smoking cessation services in the construction industry. Using participatory research methods, this study aims to: 1) Develop multilevel strategies (MLIs) to implement adaptive smoking cessation programs delivered by the safety manager on construction sites, and 2) conduct a cluster-randomized, hybrid type 1 effectiveness-implementation, 2-phase sequential multiple assignment randomized trial (SMART) to test the programs (ClinicalTrials.gov: NCT06098144). The MLIs include: 1) creating the outer setting (research investigators, stakeholders) and inner setting facilitation (companies' advisory committee, study champion), 2) conducting observational field assessments of workflows, 3) training safety managers to deliver the intervention, and 4) conducting implementation process evaluations. In SMART, 32 construction sites within 8 companies with 608 CWs will be enrolled. In Phase 1, sites will be randomized to A1 (referral to Tobacco Quitline -TQL) or B1 (referral to TQL + nicotine replacement treatment (NRT) + 1 group behavioral counseling session). In Phase 2, responders who quit smoking at 3 months continue with the assessment only, while non-responders will be re-randomized to C (4 counseling sessions + NRT; A1 + C, B1 + C) or an extra dose of Phase 1 treatment (A2, B2). Participants will receive 4 follow-up assessments at 3, 6, 9, and 12 months. Primary outcomes are the effectiveness (12-month biomarker-confirmed prolonged abstinence) and cost-effectiveness (cost/quit, cost/quality-adjusted life-year) of A1 + A2 vs. B1 + B2 and A1 + C vs. B1 + C. The secondary outcome is the feasibility of the program's implementation. We hypothesize that B1 + B2 will outperform A1 + A2, and B1 + C will outperform A1 + C. This project will generate novel scientific evidence on the effectiveness, cost-effectiveness, and implementation feasibility of smoking cessation programs in the construction industry.

The Addiction Health Services Research (AHSR) Conference has been held since 2002. This Conference brings together researchers, graduate students, policymakers, and treatment providers to focus improving the organization, distribution, and financing of healthcare resources for prevention/care of SUD. The AHSR 2023 Conference took place in New York City, October 18–20 th , and was hosted by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH; cherishresearch.org). Attended by more than 300 participants, the Conference comprised several themes relating to the latest research on addiction health services delivery, financing, and impact. The agenda also included pre-conference workshops, distinguished plenary speakers, a multitude of networking opportunities, and career support for early-stage and minority investigators. AHSR 2023 featured 3 plenary sessions, 120 oral presentations, and 143 poster presentations from academics throughout the world. Overall, AHSR 2023 provided numerous opportunities to advance the field of addiction health services research. The state-of-the-art techniques and insights gained by attending scholars will position them to be change-agents in the addiction field going forward.

Capturing costs associated with prevention activities related to substance use disorders (SUD) and mental health (MH) is critical. In this study, Trust Based Relational Intervention (TBRI®), an attachment-based, trauma-informed intervention, is conceptualized as a preventive intervention to reduce substance and opioid use among youth involved with the legal system. When implemented alongside community reentry, TBRI leverages family systems as youth transition from secure residential care into communities through emotional guidance and role modeling. Activity-based cost (ABC) analysis was used to guide cost data collection and analysis for both start-up and implementation of the TBRI intervention. Start-up costs were estimated using data across eight sites during their start-up phase. All components, activities, personnel involved, and time associated with implementation of TBRI sessions according to protocol were defined. National wages were extracted from O*NET and utilized to calculate total costs for each TBRI component. Total and average TBRI intervention costs were calculated with a breakdown by TBRI sessions and number of staff and participants. A sensitivity analysis was conducted to estimate TBRI implementation costs with travel. The total cost for the TBRI intervention, representing 42 sessions, ranges from 6,927, without travel expenses or12,298, with travel expenses. The average per family cost ranges from 1,385 (without travel) to2,460 (with travel). Costs are primarily generated by time investments from primary interventionists. The sensitivity analysis shows costs for responsive coaching would double with travel costs included. Results aim to show that using ABC for prevention activities, like TBRI, to understand cost drivers can facilitate future intervention sustainability. Clinical Trail.gov ID: NCT04678960.

Abstract Background Although behavioral interventions show some promise for reducing stimulant use and achieving durable viral suppression in sexual minority men (SMM) with HIV, scalable mHealth applications are needed to optimize their reach and cost-effectiveness. Methods Supporting Treatment Adherence for Resilience and Thriving (START) is a randomized controlled trial (RCT) testing the efficacy and cost-effectiveness of a mHealth application that integrates evidence-based positive affect regulation skills with self-monitoring of adherence and mood. The primary outcome is detectable HIV viral load (i.e., > 300 copies/mL) from self-collected dried blood spot (DBS) specimens at 6 months. Secondary outcomes include detectable DBS viral load at 12 months, self-reported stimulant use severity, anti-retroviral therapy (ART) adherence, and positive affect over 12 months. A national sample of up to 250 SMM with HIV who screen positive for stimulant use disorder and reporting suboptimal ART adherence is being recruited via social networking applications through April of 2024. After providing informed consent, participants complete a run-in period (i.e., waiting period) including two baseline assessments with self-report measures and a self-collected DBS sample. Those who complete the run-in period are randomized to either the START mHealth application or access to a website with referrals to HIV care and substance use disorder treatment resources. Participants provide DBS samples at baseline, 6, and 12 months to measure HIV viral load as well as complete self-report measures for secondary outcomes at quarterly follow-up assessments over 12 months. Discussion To date, we have paid $117,500 to advertise START on social networking applications and reached 1,970 eligible participants ($59.77 per eligible participant). Although we identified this large national sample of potentially eligible SMM with HIV who screen positive for a stimulant use disorder and report suboptimal ART adherence, only one-in-four have enrolled in the RCT. The run-in period has proven to be crucial for maintaining scientific rigor and reproducibility of this RCT, such that only half of consented participants complete the required study enrollment activities and attended a randomization visit. Taken together, findings will guide adequate resource allocation to achieve randomization targets in future mHealth research SMM with HIV who use stimulants. Trial Registration This protocol was registered on clinicaltrials.gov (NCT05140876) on December 2, 2021.

BACKGROUND:Communities That HEAL (CTH) is a novel, data-driven community-engaged intervention designed to reduce opioid overdose deaths by increasing community engagement, adoption of an integrated set of evidence-based practices, and delivering a communications campaign across healthcare, behavioral-health, criminal-legal, and other community-based settings. The implementation of such a complex initiative requires up-front investments of time and other expenditures (i.e., start-up costs). Despite the importance of these start-up costs in investment decisions to stakeholders, they are typically excluded from cost-effectiveness analyses. The objective of this study is to report a detailed analysis of CTH start-up costs pre-intervention implementation and to describe the relevance of these data for stakeholders to determine implementation feasibility. METHODS:This study is guided by the community perspective, reflecting the investments that a real-world community would need to incur to implement the CTH intervention. We adopted an activity-based costing approach, in which resources related to hiring, training, purchasing, and community dashboard creation were identified through macro- and micro-costing techniques from 34 communities with high rates of fatal opioid overdoses, across four states-Kentucky, Massachusetts, New York, and Ohio. Resources were identified and assigned a unit cost using administrative and semi-structured-interview data. All cost estimates were reported in 2019 dollars. RESULTS:State-level average and median start-up cost (representing 8-10 communities per state) were $268,657 and $175,683, respectively. Hiring and training represented 40%, equipment and infrastructure costs represented 24%, and dashboard creation represented 36% of the total average start-up cost. Comparatively, hiring and training represented 49%, purchasing costs represented 18%, and dashboard creation represented 34% of the total median start-up cost. CONCLUSION:We identified three distinct CTH hiring models that affected start-up costs: hospital-academic (Massachusetts), university-academic (Kentucky and Ohio), and community-leveraged (New York). Hiring, training, and purchasing start-up costs were lowest in New York due to existing local infrastructure. Community-based implementation similar to the New York model may have lower start-up costs due to leveraging of existing infrastructure, relationships, and support from local health departments.

Introduction Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia.Methods and analysis KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness.Ethics and dissemination The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings.Trial registration number NCT05657106.

OBJECTIVES:Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions. METHODS:We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs. RESULTS:We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC. CONCLUSIONS:OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.

Background: Given the personal and public consequences of untreated/undertreated OUD among persons involved in the justice system, an increasing number of jails and prisons are incorporating medication for opioid use disorder (MOUD) into their system. Estimating the costs of implementing and sustaining a particular MOUD program is vital to detention facilities, which typically face modest, fixed health care budgets. We developed a customizable budget impact tool to estimate the implementation and sustainment costs of numerous MOUD delivery models for detention facilities. Methods: The aim is to describe the tool and present an application of a hypothetical MOUD model. The tool is populated with resources required to implement and sustain various MOUD models in detention facilities. We identified resources via micro-costing techniques alongside randomized clinical trials. The resource-costing method is used to assign values to resources. Resources/costs are categorized as (a) fixed, (b) time-dependent, and (c) variable. Implementation costs include (a), (b), and (c) over a specified timeframe. Sustainment costs include (b) and (c). The MOUD model example entails offering all three FDA-approved medications, with methadone and buprenorphine provided by vendors, and naltrexone by the jail/prison facility. Results: Fixed resources/costs are incurred only once, including accreditation fees and trainings. Time-dependent resources/costs are recurring, but fixed over a given time-period; e.g., medication delivery and staff meetings. Variable resources/costs are those that are a direct function of the number of persons treated, such as the medication provided to each patient. Using nationally representative prices, we estimated fixed/sustainment costs to be $2919/patient, over 1 year. This article estimates annual sustainment costs to be $2885/patient. Conclusion: The tool will serve as a valuable asset to jail/prison leadership, policymakers, and other stakeholders interested in identifying/estimating the resources and costs associated with alternative MOUD delivery models, from the planning stages through sustainment.