Evaluation of Kentucky Access to Recovery Linkage Strategy

The Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) estimated that for the 12-month period ending September 2021 in the United States (US), there were 99,543 confirmed drug overdose deaths with 104,288 deaths predicted to be the final total number, a 19.9% increase from the 12-month period before (NCHS, 2021). Kentucky had the 2nd highest age-adjusted drug overdose fatality rate (51.5 deaths/100,000 persons) in the US in 2020 that is 75% above the US rate (29.5/100,000) (NCHS, 2021) with 2,187 deaths, a 49% increase over the number of deaths in 2019 (Steel, 2021). To address the elevated numbers of drug overdose fatalities, effective strategies are needed to link persons in SUD treatment or those with illicit SUD not yet in treatment with recovery support services (RSSs) to build recovery capital, maintain sustained recovery, and reduce resumption of illicit substance use and drug overdoses. Access to Recovery (ATR) is a linkage strategy supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) that was implemented by Kentucky in 2019 to link vulnerable populations with opioid and/or stimulant SUDs to RSS (including evidence-based recovery housing) and other community services using a voucher system and, if needed, re-link clients to RSS following resumption of illicit substance use. The Kentucky ATR (KATR) strategy is a 25-county program that links residents of those counties with an illicit SUD in treatment or early recovery (those recently released from incarceration, veterans, pregnant/post-partum or under-18 parenting, or those who are part of a recently completed [< 1 year] recovery program) to RSS such as recovery housing, and other RSSs, such as transportation and employment. To address the gap in accessibility of RSS that often occurs in vulnerable and low-income populations, the KATR linkage approach uses vouchers as a linkage strategy for individuals in SUD treatment who have no other funding options to acquire critical RSS. As such, the KATR linkage through vouchers is a “last resort” approach for linking to recovery services. The purpose of this proposal is to perform a rigorous process and outcome evaluation of this “last resort” voucher strategy of linking by accomplishing the following specific aims: Specific Aim 1: Conduct a process evaluation of the KATR linkage strategy to determine whether the KATR strategy is acceptable and accessible to vulnerable populations with illicit SUD who are linked to RSS; identify barriers and facilitators to KATR implementation; and assess the extent to which the KATR strategy was implemented as designed; Specific Aim 2: Conduct an outcome and impact evaluation of the KATR linkage strategy; and Specific Aim 3: Evaluate the long-term effectiveness of implementing vouchers as a linkage strategy in a population requiring RSSs when no other funding sources are available. A within-subjects design will be used to test the effectiveness of the KATR “last resort” voucher linkage approach to reduce the risk of nonfatal and fatal overdoses by (a) increasing an individual’s recovery capital; (b) reducing resumption of illicit substance use; and (c) promoting relinking to RSS if illicit substances are resumed. Kentucky provides a well-suited environment to study the effectiveness of linkage strategies to link individuals with illicit SUD to RSSs because of the elevated poverty rates, rurality, criminal justice involvement, and drug overdose fatality rates in the KATR service areas. The results of this study may be used to inform the development and dissemination of enhanced targeted ATRs in the US to serve individuals experiencing similar SUD health access disparities.