Implementation science (IS) is an emerging discipline that offers frameworks, theories, measures, and interventions to understand both the effective organizational change processes and the contextual factors that affect how well an innovation operates in real-world settings. In this article, we present an overview of the basic concepts and methods of IS. We then present six studies where IS was used as a means to understand implementation of a new innovations designed to improve the health and well-being of individuals under criminal legal system supervision. We discuss how IS has developed new knowledge on how to implement efficacious innovations and suggesting future research needed to further our understanding of implementation and sustainability of innovations in the legal context.

Background: Justice-involved youth have high rates of mental health and substance use disorders which are linked to re-offending. However, research on the impact of behavioral health issues, especially among those on community supervision, is limited.Objectives: This study examines the effects of co-occurring mental health and substance use indicators on recidivism among youth on probation using data from the JJ-TRIALS multi-site cooperative. We compare hazard rates for recidivism by type of behavioral health indicator.Methods: The sample includes 3,023 female and 9,617 male (N = 12,649) youth who were followed for up to 1,415 days after initial probation referral.Results: Cox proportional hazard models revealed that those with mental health issues only (HR = 1.5, p < .001), substance use only (HR = 1.5, p < .001), and co-occurring conditions (HR = 3.5, p < .001) had a greater recidivism hazard than those with no behavioral health issues. Survival analysis indicated that those with co-occurring indicators had a faster time to recidivism compared to other behavioral health groups. There was a significant interaction between behavioral health status and treatment initiation, particularly for those with substance use (HR = 0.34, p < .001) and co-occurring indicators (HR = 0.89, p = .02).Conclusion: Behavioral health affects recidivism among justice-involved youth. Treatment initiation, while shown to reduce recidivism, may differentially impact reoffending depending on specific behavioral health needs. Findings highlight the need for enhanced assessment and expanded co-occurring treatment and emphasize the importance of matching youth to appropriate community-based, integrated services to improve justice-related outcomes.

Multisite implementation research in justice and health settings often does not systematically assess differential degrees of project involvement among participating sites, despite its implications for both research and the intervention. Tracking organization and participant involvement across sites, when attempted, has typically entailed the use of discrete and sometimes disjointed fidelity measures that may not accurately reflect engagement with a project. This article advances a more comprehensive and sophisticated conceptual model for measuring and monitoring site engagement. This conceptual model was developed from a literature review of the implementation science and related disciplines while being informed by multisite project implementation experience. We propose the Site Engagement Activity Model Leveraging Implementation Science (SEAMLIS), a conceptual model that holistically identifies the breadth of agency participation (diverse activities such as trainings, meetings, etc.) and duration of site engagement (participation levels from inception to completion) to be measured, assessed, and reported. We also describe Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), a 36-site implementation research project, as an illustrative case example of our proposed model. We then operationalize all proposed domains and subdomains and specify key measures from the project. We provide analytical recommendations for the application and future research of the proposed model in health and justice settings. In multisite implementation research, site engagement could be fruitfully used as an independent, dependent, or intervening (moderating or mediating) variable. NCT02672150, February 3, 2016.

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.

IntroductionCompared to the general U.S. adolescent population, young people involved in the juvenile justice system are at greater risk of experiencing substance use (SU) issues. There are critical opportunities across the juvenile justice continuum, at points of interface with community-based treatment services, to screen and assess for SU issues, identify unmet treatment needs, and refer those in need to treatment. The treatment referral process is, however, complex, and contingent on a seamless nexus between juvenile justice operations and the wider treatment provider landscape. Given the lack of successful SU referrals among justice-involved youth and the variable referral rates across jurisdictions, this study's aim is to provide a qualitative, explanatory understanding of the conditions that together contribute to successful referring practices.MethodsThe study is based on an analysis of a qualitative dataset comprising focus group data with probation and community-based behavioral health treatment staff working in 31 sites in 6 different states as part of the clustered randomized trial of an organizational change intervention known as JJ-TRIALS (Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System). The data contain respondents' narratives on the achievements, successes, and challenges with implementing the intervention. The data were analyzed through a combination of strategies to identify the conditions that both facilitate and impede referral processes between probation offices and community-based SU treatment providers.ResultsParticipants across sites discussed the positive impacts that the JJ-TRIALS intervention had on their improved ability to communicate, collaborate, and collect data. From the interviews, seven main conditions were observed to contribute to successful SU treatment referral practices: (1) communication (inter-organizational); (2) collaboration; (3) data-driven practices; (4) family engagement; (5) institutionalized policy and referral documentation; (6) efficient referral policies and procedures; and (7) suitable and accessible system of treatment providers.ConclusionFindings highlight the value of a holistic understanding of successful treatment referrals for justice-involved youth and help inform research and practice efforts to identify and measure the many dimensions of referral-making at the interface of juvenile probation and behavioral health services.

In “Cause, Effect, and the Structure of the Social World” (2023), Megan Stevenson makes a claim that randomized controlled trials (RCTs) have not had a significant effect in criminal justice settings. She then draws the conclusion that the gold standard for research designs, RCTs, are inherently incapable of doing so, demonstrating that the social world they intervene on is too complex, but also too resilient, to respond to the types of interventions that are evaluable by RCT. She calls the insistence that RCTs can work an “engineer’s” view of the world, which she discards as a myth. The argument then conflates RCTs with other methods of generating and sustaining change in organizations and systems, and closes suggesting RCTs should be discarded for less rigorous but more sweeping means of social reform. This article proceeds as follows: It characterizes Stevenson’s argument, which she asserts is empirical, as a de facto meta-analysis of criminal justice RCTs executed as a heuristic and presented in a narrative format. It argues that if a formal meta-analysis would be rendered invalid by violating established protocols, then a heuristic analysis that commits the same errors would be invalid as well. The analysis then presents the prohibitions on pooling studies with heterogeneous designs, interventions, outcomes, and metrics for the purpose of meta-analysis. It demonstrates that Stevenson pools a wide range of heterogenous studies, rendering her empirical meta-analytic claims problematic. It is true that many criminal justice RCTs have produced null or lackluster results—which also constitute an important outcome—and attempts to replicate significant findings have often been unsuccessful. This is not unique to criminal justice: psychology was recently in crisis when it was determined few of its most prominent studies could be replicated. However, less rigorous methods of reform do not solve this problem. Instead, more comprehensive research designs such as hybrid implementation/effectiveness trials can reveal aspects of our social world that impact external validity and generalizability. Findings from these studies can help illuminate the conditions that impact outcomes and sustainably modify highly resilient human behaviors. These methods arise from techniques in medicine and public health, which Stevenson brackets off as fundamentally different from criminal justice. This type of thinking may be the actual myth that prevents progress.

Background The outcomes of planned implementation efforts have been mixed, with some applications failing to achieve the desired change or impact. While reasons for mixed findings in implementation research are multifaceted (e.g., Damschroder et al., 2009, 2022), how the implementation strategy (IS) was deployed (i.e., integrity) and its impact on the implementation outcomes of evidence-based innovations (EBIs) is under-studied and warrants further clarification. Method This article builds on the IS fidelity and mechanisms of change literature to create the Implementation Strategy Integrity Framework (ISIF). The ISIF was developed by a set of implementation science researchers in the Justice Community Opioid Innovation Network seeking to document the role of implementation strategies in influencing EBI outcomes. Results The authors identified four areas of documentation and measurement to examine the role of IS integrity on EBI outcomes. (a) Implementation Strategy Rigor (i.e., adherence, dose, and quality) requires those implementing the strategy/strategies to specify them, document adherence to the planned strategies, quality of execution, and any adaptations made. (b) Target User Responsiveness documents the extent and quality of targeted users’ participation in IS activities and how well the target users perform their roles in conducting actions intended by the implementation strategies. (c) Target Mechanism Activation notes to what degree the implementation strategies achieved the intended impact(s) on targeted factors that facilitate EBI use. Finally, (d) these three areas are combined with selected Inner and Outer Context variables to explain IS integrity’s potential moderating and mediating effects on EBI outcomes. Conclusions A framework that can define the integrity of an IS and allow for its subsequent use as an explanatory variable in EBI outcomes is necessary for better elucidating mechanisms of action. The ISIF offers a structured approach to operationalize, measure, and evaluate the application and related impacts of implementation strategies.

At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS.

As “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice,” implementation science (IS) offers the potential to translate effective innovations in policing across agencies and local contexts with fidelity and sustainability in support of a commitment to evidence-based policing (EBP). Despite this potential, and its widespread use in adjacent fields facing similar challenges, implementation science remains almost completely unstudied and unutilized in police settings. To fill these gaps in research and practice, this paper provides an orientation to IS for police researchers and practitioners. It recounts EBP’s historical roots in an evidence-based approach to health care, demonstrates the commonalities that make IS as natural to policing as medicine, and surveys the existing literature on the employment of IS in policing. It adapts a conceptual model of IS to policing, presents two well-developed frameworks, and introduces three types of hybrid implementation/effectiveness trials suitable for use in dynamic police settings. It then provides illustrative cases in policing where the use of IS would be apt, and highlights the importance of the de-implementation of substandard or problematic practices as a key but often overlooked aspect of IS. It concludes by discussing how police practices that fully embrace evidence will nonetheless be guided by contestable values and norms, and how IS provides a way to address this concern. The paper provides research and practice agendas for integrating IS into EBP as police seek to adopt evidence-informed practices that deliver public safety, respect rights, and increase community satisfaction and trust.

BackgroundDespite the heightened risk for substance use (SU) among youth in the juvenile justice system, many do not receive the treatment that they need.ObjectivesThe purpose of this study is to examine the extent to which youth under community supervision by juvenile justice agencies receive community-based SU services and the factors associated with access to such services.MethodsData are from a nationally representative sample of Community Supervision (CS) agencies and their primary behavioral health (BH) partners. Surveys were completed by 192 CS and 271 BH agencies.ResultsSU services are more often available through BH than CS for all treatment modalities. EBPs are more likely to be used by BH than by CS. Co-location of services occurs most often in communities with fewer treatment options and is associated with higher interagency collaboration. Youth are more likely to receive services in communities with higher EBP use, which mediates the relationship between the availability of SU treatment modalities and the proportion of youth served.ConclusionFindings identify opportunities to strengthen community systems and improve linkage to care.

INTRODUCTION:Many youth under community supervision have substance use and co-occurring mental health issues. Yet, access to treatment is limited, and many programs cannot address co-occurring disorders. This study examines how co-occurring symptoms among youth on probation affect referral to and initiation of treatment. We hypothesize that both referral and initiation rates will be lower for youth with any co-occurring indicators. METHODS:This study collected administrative data from 14 sites in three states between March 2014 and November 2017 using JJ-TRIALS, a cluster randomized trial. Among 8552 youth in need of treatment (screened as having a substance use problem, drug possession arrest, positive drug test, etc.), 2069 received a referral to treatment and 1630 initiated treatment among those referred. A co-occurring indicator (n = 2828) was based on symptoms of an internalizing and/or externalizing issue. Descriptive analyses compared referral and initiation by behavioral health status. Two-level mixed effects logistic regression models estimated effects of site-level variables. RESULTS:Among youth in need with co-occurring internal, external, or both indicators, only 16 %, 18 %, and 20 % were referred to treatment and of those referred, 63 %, 69 %, and 57 % initiated treatment, respectively. Comparatively, 27 % and 83 % of youth with a substance use only indicator were referred and initiated treatment respectively. Multi-level multivariate models found that, contrary to our hypothesis, co-occurring-both (p = 0.00, OR 1.44) and co-occurring-internal indicators (p = 0.06, OR 1.25) predicted higher referral but there were no differences in initiation rates. However, there was substantial site-level variation. CONCLUSIONS:Youth on probation in need of substance use treatment with co-occurring issues have low referral rates. Behavioral health status may influence youth referral to treatment depending on where a youth is located. Depending on the site, there may be a lack of community programs that can adequately treat youth with co-occurring issues and reduce unmet service needs.

At the Crossroads in the Opioid Overdose Epidemic: Will Evidence-Based “Radical” but Rational Drug Policy Strategies Prevail? Gerald J. Stahler PhD, Jeremy Mennis PhD, and Steven Belenko PhD Affiliation Gerald J. Stahler and Jeremy Mennis are with the Department of Geography and Urban Studies, Temple University, Philadelphia, PA. Steven Belenko is with the Department of Criminal Justice, Temple University. CopyRightCorrespondence should be sent to Gerald Stahler, PhD, Department of Geography and Urban Studies, 343 Gladfelter Hall, 1115 Pollett Walk, Temple University (025-27), Philadelphia, PA 19122 (e-mail: jstahler@temple.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. CONTRIBUTORS G. J. Stahler conceptualized the editorial and outlined the first draft. All authors drafted and edited the editorial. https://doi.org/10.2105/AJPH.2023.307320 Accepted: April 15, 2023 Published Online: June 07, 2023

Juvenile Drug Treatment Courts (JDTC) emerged in the mid-1990s as a potential solution to concern about substance use among youth in the juvenile justice system (JJS). Despite substantial research, findings on the JDTC effectiveness for reducing recidivism and substance use remain inconsistent, hampered by methodological problems. In 2016, the Office of Juvenile Justice and Delinquency Prevention published research-based JDTC Guidelines for best practices, and funded technical assistance for implementation and a multisite national outcomes study among JDTCs implementing the Guidelines. Ten sites were originally selected for this study, with a JDTC and Traditional Juvenile Court (TJC) participating. In two sites, moderate- to high-risk youth were randomized to JDTC or TJC, and in eight sites, a regression discontinuity design assigned moderate- to high-risk youth to JDTC, and other youth to TJC. Findings from four sites with sufficient cases and follow-up rates indicated that JDTCs reduced cannabis use, increased access to mental health services, and reduced recidivism. However, the effects were small to moderate, with positive impacts mainly observed among high-risk youth. The impacts of JDTCs may have been attenuated because Guidelines implementation was inconsistent across courts, and some TJCs implemented elements of the Guidelines, blurring the distinction between JDTCs and TJCs.

Aims: To examine the use and association of medications for opioid use disorder (MOUD) with treatment completion and retention for criminal justice referred (CJR) admissions to residential treatment. Methods: A retrospective analysis of the Treatment Episode Dataset-Discharge (TEDS-D; 2015-2018) for adults (N = 205,348) admitted to short-term (ST) (< 30 days) or long-term (LT) (>30 days) residential treatment for OUD. Outcomes were MOUD in treatment plans, and treatment completion and retention (ST >10 days; LT > 90 days). Logistic regression analyses were conducted separately for ST and LT settings. Results: CJR admissions were less likely to have MOUD than non-CJR admissions (ST, 11% vs. 21%; LT, 10% vs. 24%, respectively) and were more likely to complete and be retained in treatment. In ST settings, MOUD was associated with higher likelihood of treatment completion and retention. In LT settings, MOUD was associated with higher likelihood of treatment retention and lower likelihood of treatment completion. These associations tended to be slightly weaker for CJR admissions, with the exception of treatment completion in LT settings, but the moderating effect size of CJR status in all models was very small. Small differences in the moderating effect of CJR status by race and ethnicity were observed in LT settings. Conclusions: MOUD is greatly under-utilized for CJR patients, and given that MOUD was associated with positive outcomes, there is a critical need to find ways to increase access to MOUD for CJR patients in residential treatment. Race and ethnicity appear to have relatively little impact on outcomes.

Background Most justice-involved youth are supervised in community settings, where assessment and linkage to substance use (SU) treatment services are inconsistent and fragmented. Only 1/3 of youth with an identified SU need receive a treatment referral and even fewer initiate services. Thus, improving identification and linkage to treatment requires coordination across juvenile justice (JJ) and behavioral health (BH) agencies. The current study examines the comparative effectiveness of two bundled implementation intervention strategies for improving SU treatment initiation, engagement, and continuing care among justice-involved youth supervised in community settings. Exploration, Preparation, Implementation, Sustainment (EPIS) served as the conceptual framework for study design and selection/timing of implementation intervention components, and the BH Services Cascade served as the conceptual and measurement framework for identifying and addressing gaps in service receipt. Methods Part of a larger Juvenile-Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) Cooperative, this study involved a multisite, cluster-randomized control trial where sites were paired then randomly assigned to receive Core (training teams on the BH Services Cascade and data-driven decision making; supporting goal selection) or Core+Enhanced (external facilitation of implementation teams) intervention components. Youth service records were collected from 20 JJ community supervision agencies (in five states) across five study phases (baseline, pre-randomization, early experiment, late experiment, maintenance). Implementation teams comprised of JJ and BH staff collaboratively identified goals along the BH Cascade and used data-driven decision-making to implement change. Results Results suggest that Core intervention components were effective at increasing service receipt over time relative to baseline, but differences between Core and Core+Enhanced conditions were non-significant. Time to service initiation was shorter among Core+Enhanced sites, and deeper Cascade penetration occurred when external facilitation (of implementation teams) was provided. Wide variation existed in the degree and nature of change across service systems. Conclusions Findings demonstrate the criticality of early EPIS phases, demonstrating that strategies provided during the formative exploration and preparation phases produced some improvement in service receipt, whereas implementation-focused activities produced incremental improvement in moving youth farther along the Cascade.

Introduction: Youth involved in the justice system have high rates of alcohol and other drug use, but limited treatment engagement. JJ-TRIALS tested implementation activities with community supervision (CS) and behavioral health (BH) agencies to improve screening, identification of substance use service need, referral, and treatment initiation and engagement, guided by the BH Services Cascade and EPIS frameworks. This paper summarizes intervention impacts on referrals to treatment among youth on CS. Methods: This multisite cluster-randomized trial involved 18 matched pairs of sites in 36 counties in seven states randomly assigned to core or enhanced conditions after implementing the core intervention at all sites for six months. Enhanced sites received external facilitation for local change team activities to reduce unmet treatment needs; Core sites were encouraged to form interagency workgroups. The dependent variable was percentage referred to treatment among youth in need (N = 14,012). Two-level Bayesian regression assessed factors predicting referral across all sites and time periods. Generalized linear mixed models using logit transformation tested two hypotheses: (H1) referrals will increase from baseline to the experimental period, (H2) referral increases will be larger in enhanced sites than in core sites. Results: Although the intervention significantly increased referral, condition did not significantly predict referral across all time periods. Youth who tested drug positive, had an alcohol/other drug-related or felony charge, were placed in secure detention or assigned more intensive supervision, or who were White were more likely to be referred. H1 (p < .05) and H2 (p < .0001) were both significant in the hypothesized direction. Interaction analyses comparing site pair differences showed that findings were not consistent across sites. Conclusions: The percentage of youth referred to treatment increased compared with baseline overall, and enhanced sites showed larger increases in referrals over time. However, variations in effects suggest that site-level differences were important. Researchers should carry out mixed methods studies to further understand reasons for the inconsistent findings within randomized site pairs, and how to further improve treatment referrals across CS and BH systems. Findings also highlight that even when CS agencies work collaboratively with BH providers to improve referrals, most justice-involved youth who need SU services are not referred.