PART A Local Drug Courts Tx of OUD.v3

Supporting Statement A
For

Survey on the Treatment of Opioid Use Disorders

OFFICE OF NATIONAL DRUG CONTROL POLICY (ONDCP)
EXECUTIVE OFFICE OF THE PRESIDENT
March 10, 2020

Jayme Delano
Deputy Director, National HIDTA Program Office
Office of National Drug Control Policy
Executive Office of the President
Street address
Washington, DC ZIP
Phone: 202-395-6794
Email:
Jayme_A_Delano@ondcp.eop.gov

INFORMATION COLLECTION TITLE: Survey on the Treatment of Substance Use
Disorders
COLLECTION INSTRUMENT: Survey on the Treatment of Substance Use Disorders
(Internet Based Survey)
AUTHORITY: 21 U.S.C. § 1703(b)(21)(B)(iii)
The Substance-Use Disorder Prevention that Promotes Opioid Recovery and Treatment for
Patients and Communities Act (SUPPORT Act), 21 U.S.C. §§ 1701 et seq. authorizes the
ONDCP Director to request data from any entity that will assist the agency in formulating
national drug control policies, goals, objectives and priorities. See 21 U.S.C. §
1703(b)(21)(B)(iii). Moreover, the information that ONDCP collects from data collection
instruments enables ONDCP to receive up-do-date information that is vital to measuring the
effectiveness of federal, state, and local drug control programs. The Consolidated
Appropriations Act, 2020, Pub. Law. Pub. L. No. 116-93, also authorizes ONDCP to incur
expenses for drug control research activities.

PART A. JUSTIFICATION

A.1 CIRCUMSTANCES MAKING THE COLLECTION OF INFORMATION
NECESSARY
Background
The human and economic toll of the opioid epidemic continues to burden the United States.
According to the Center for Disease Control (CDC), drug overdose death rates from 2013 to
2017 increased in most states, i with more than 70,000 people dying from a drug overdose in
2017. About 68 percent of overdose deaths from that year involved a prescription or illicit
opioid ii. Additionally, in 2015 the economic cost of the opioid epidemic was over $500 billion
or almost 3% of GDP for that year. iii Therefore, it is imperative that decision makers in the
behavioral health space implement and promote evidence-based treatment to combat the
tremendous societal strain of the opioid epidemic. Medication assisted treatment (MAT) is well
established as a clinically effective intervention for the successful treatment of opioid addiction
and is promoted as a best practice standard among federal entities. iv Given the prevalence of
opioid use disorder among individuals within the criminal justice system, v research has explored
the effectiveness of MAT in reducing opioid use disorders (OUD) among this population with
positive results. A recent meta-analysis of MAT among samples of incarcerated individuals
found that methadone treatment increased treatment engagement while reducing illicit opioid use
and injection drug use. vi
Drug courts are intended to divert those who commit drug-related offenses away from detention
or incarceration and into treatment. vii As of 2018, there were about 1,550 adult drug courts in
operation nationally. viii Research supports that those reporting OUD are significantly more likely
to be justice system-involved compared to their non-opioid using counterparts; and, history of
justice involvement increases for individuals as their opioid use increases. ix Therefore, drug

courts are uniquely positioned within the justice system to access this high-risk population and
divert them away from costly incarceration and into the treatment they need. A comprehensive
public health approach to the opioid epidemic must consider the role of MAT within adult drug
courts, however, as discussed below, limited research has been conducted on this relationship.
Utilization of MAT in Adult Drug Courts
In 1999, the first national survey exploring the availability of MAT, specifically methadone, in
adult drug courts was conducted. x Of 212 sampled drug courts, methadone was provided in 39%
of them. The next national survey was conducted in 2013 with a sample of 93 drug courts from
49 states, DC, and Puerto Rico. Researchers found that 56% of drug courts reported that at least
some of their opioid dependent participants were receiving MAT. The most frequently cited
factor for limited or no availability of MAT was cost in the case of buprenorphine treatment
(43%) and that the court does not allow it (52%) in the case of methadone treatment. xi
Additionally, in 2012, a survey on MAT practices and policies from 50 criminal justice agencies
across the country, including 8 drug courts, found that MAT was provided in less than half (3) of
sampled courts. When surveyed about factors which influence the use of MAT, drug courts cited
liability concerns, a lack of qualified medical staff, and reimbursement difficulties. xii National
data from 2014 found that underutilization of MAT is evident in the justice system more broadly
with only one in twenty justice involved adults referred to OUD treatment receiving MAT. The
study found that specifically courts and diversionary programs were the least likely to refer to
MAT. xiii A study of a narrow convenience sample of 20 drug courts in Indiana found that
roughly half of the programs required participants to discontinue methadone or buprenorphine
within 30 days regardless of medical indication or necessity. xiv
Most recently, a 2019 single-site study over four years, sampling 187 adult drug court
participants with an opioid addiction, found that only 46% received MAT. xv Other studies have
documented increased use of MAT in some drug courts; however, serious implementation
challenges persist. At least three studies found no improvements in outcomes for drug court
participants receiving MAT, which apparently resulted from unwarranted delays in starting the
medication regimens, negative attitudes toward MAT held by many staff members and fellow
participants, and substantially greater use of extended-release naltrexone compared to methadone
or buprenorphine, which may not have been medically indicated. xvi xvii xviii Because naltrexone is
nonaddictive, non-intoxicating and has fewer side effects than methadone and buprenorphine,
some drug courts may favor access to this medication or require it to be used as a front-line
regimen before trying other medications. This practice is unjustified for several reasons, not least
of which is the fact that overriding patient preference and medical judgment in the choice of
medications is associated with significantly lower treatment retention and success rates. xix xx
Moreover, because physiological tolerance to opioids declines substantially while patients are
receiving naltrexone, participants who drop out of treatment face an increased likelihood of
overdose and death if they discontinue the regimen and return to previous levels of opioid use. xxi
xxii
Therefore, it is critical to learn whether drug courts are unduly favoring the use of naltrexone,
and what educational efforts are needed to increase acceptance and use of other addiction
medications.

Despite its evidenced effectiveness and wide acceptance as an opioid dependence intervention,
MAT is underutilized in drug courts. Barriers to more universal utilization still exist and center
around practical considerations such as cost, court policy restrictions, liability and lack of local
MAT providers. Historically negative attitudes toward MAT and a belief that the treatment
substitutes one addiction for another, also may inhibit MAT expansion in courts despite contrary
evidence. xxiii A survey of court employees in Indiana explored personnel attitudes toward MAT
and found a positive association between trainings and positive attitudes towards the treatment
suggesting that educational opportunities for drug court staff could aid in more universal
utilization of MAT in courts. xxiv Additionally, the most recent 2013 national survey of MAT in
drug courts found the most frequently selected response category for the majority of attitudinal
questions was “uncertain” xxv underscoring a significant knowledge gap among court staff.
Need for More Research
In order to develop a more targeted response to the underutilization of MAT in adult drug courts,
more data surrounding current policy and practices is needed, including what training and
educational opportunities are available to drug court personnel surrounding MAT. The seven
years since the most recently disseminated national survey has seen an evolution of the opioid
crisis in conjunction with policy responses from states. However, the exact status of the
accessibility and availability of MAT to drug court participants remains undocumented. The
landscape needs to be reassessed to promote established best practice standards in addressing the
needs of opioid addicted individuals in adult drug courts. The proposed survey, the Survey on the
Treatment of Opioid Use Disorders (the survey), will fill this knowledge deficiency.

A.2 PURPOSE AND USE OF THE INFORMATION COLLECTION
The Office of National Drug Control Policy has deemed it necessary to investigate how adult
drug courts are responding to the opioid epidemic. The electronically administered proposed
survey will help ONDCP learn more about local adult drug courts’ efforts to serve persons
suffering from opioid use disorders, focusing particularly on the use of MAT for OUD. As
mentioned earlier, previous surveys have found that nearly half of drug courts are not using
MAT or had blanket prohibitions against methadone or buprenorphine. At the same time,
ONDCP funded a suite of resources to increase use of MAT in treatment courts, including online
and in-person training workshops, practitioner fact sheets, pocket guides for staff members and
participants, professional tool kits, and sample policies and procedures materials. In addition,
CSAT and BJA amended their funding conditions for drug court discretionary grants to require
drug courts to allow participants access to all forms of MAT, including methadone and
buprenorphine. The proposed survey will examine local-level MAT efforts in adult drug courts,
the availability and accessibility of MAT in these courts, and factors limiting MAT use. Survey
participants will come from a sample of all adult drug courts, specifically the 269 counties and
county-equivalents across the U.S. that are the most highly impacted by the opioid epidemic
(The sampling methodology is detailed in Supporting Statement B). The National Association of

Drug Court Professionals (NADCP) and its partner Carnevale Associates, LLC (CALLC) will
conduct the survey and analysis effort.
The practical utility of this information is to provide comprehensive, accurate, detailed, and
temporally relevant data that is useful to federal, state and local governmental agencies and nongovernmental organizations in developing or improving MAT-related programs that serve and
treat adult drug court participants with OUD. The 42-question survey contains questions that
cover the following areas:
•
•
•
•
•
•
•
•
•
•
•
•
•

The top five substances used most frequently by drug court participants
The approximate percentage of adult drug court participants that have a moderate to
severe opioid use disorder
Any changes in the prevalence of opioid use among adult drug court participants.
If MAT for OUD is available to drug court participants
The types of MAT available, if applicable, the conditions under which MAT is available,
and the approximate proportion of drug courts clients under these conditions
If discontinued use of MAT is required as a term of program graduation
If MAT use is permitted if clients are in custody as a sanction
The professional(s) are typically responsible for making the decision to use MAT for
OUD in specific cases
The availability, use, and training of naloxone to reverse opioid overdose and mortality
When applicable, if local adult drug courts are considering expanding the use of MAT
When applicable, factors that limit the use of MAT
When applicable, the reasons local adult drug courts have for limited or no provision of
buprenorphine or methadone
Any training provided in local adult drug courts to improve the delivery of MAT for
OUD

Data from the survey will be used to inform ONDCP and its stakeholders about the current status
of the use of MAT for OUD in adult drug courts. MAT use in drug courts, the conditions under
which it is available, and the types of MAT offered are unknown. It is also unknown if drug
courts take measures to prevent opioid overdose, hence the section on naloxone availability and
training. The information collected from the survey is vital to determine ONDCP-funded
program needs, target resources, and will serve as a comparison to earlier surveys to determine if
more than half of our nation’s drug courts offer MAT as a treatment option for OUD.
A.3 USE OF INFORMATION TECHNOLOGY AND BURDEN REDUCTION
An online survey system (Cvent) will be used to make the survey easily accessible to a variety of
potential respondents and to reduce the time/burden it may take. This system is used by NADCP
to administer all of its training and post-training follow-up evaluations, thus there are no
additional staff training or costs. It automates the data collection process which reduces the
burden (time, effort and funding) to ONDCP which is supporting this effort. The team’s
preliminary assessment is that the online survey will take most respondents approximately 15
minutes, much less time than interviews or pen and paper responses. Paper versions of the survey

instrument will not be sent to respondents. However, if desired by the respondent, the survey can
be printed out to review. Raw survey data will be exported from Cvent into Microsoft Excel and
SPSS for analysis. Summarized survey results will be made available to the public on NADCP’s
website.
A Privacy Impact Assessment (PIA) was not done for this project because the records that will
be part of the survey are not designed to collect, store or retrieve Personally Identifiable
Information, such as an individual’s name or other identifier. However, a PIA will be conducted
if the ONDCP Privacy Act Officer or other entity deems necessary.
A.4 EFFORTS TO IDENTIFY DUPLICATION AND USE OF SIMILAR
INFORMATION
This survey does not duplicate any current data collection efforts that are conducted on a regular
basis or on a nationally representative sample. There are no federal surveys that request
comprehensive information on MAT. In terms of data collected by federal agencies, the Bureau
of Justice Assistance surveys its drug court grantees each January and July and asks two
questions about MAT availability and access. However, these questions are only asked of current
grantees: those receiving either a drug court planning or drug court implementation grant. This
does not represent the entire universe of drug court programs and is only two relevant questions.
From 2004 to 2016, NADCP conducted the Painting the Current Picture Survey (PCP Survey).
Every six months, NADCP collected information to provide a snapshot of the status of drug and
other problem-solving courts that was posted on the National Drug Court Institute website. This
information was collected from state and territory drug court coordinators, not at the local level.
The PCP survey contained five questions about the availability and accessibility of MAT in drug
courts, statewide MAT policies, and barriers to MAT implementation. However, the PCP Survey
is no longer conducted, and a replacement survey has not been implemented.
The last national survey of MAT in drug courts (which NADCP coauthored) was completed in
2012 (Matusow et al., 2013). This was a one-time privately funded survey, similar in scope to the
proposed effort. It was national in reach but had a small sample size due to a low response rate
and was not nationally representative. The proposed survey will have better representation to
determine whether NADCP’s efforts and those of its sponsors (ONDCP, CSAT, BJA) have been
effective in increasing uptake of MAT at the local level and enhancing practitioner knowledge
and acceptance.
A.5 IMPACT ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
The survey is designed to minimize burden on respondents. For instance, there are yes/no skip
patterns throughout the survey. Respondents are asked a question before each section to
determine if that section is relevant to them. Therefore, if a respondent answers “no” at the
beginning of a section, they are skipped through that particular section. This would especially
ease any burden for respondents from drug courts who do not permit the use of MAT. Also, there
are very few open-ended questions. Questions are primarily structured so respondents are not

required to enter exact numbers or percentages. Answer choices such as “none” “very few - less
than 10%”, “some - about 25%”, “about half”, “most - about 75%”, and “all are nearly all” are
provided as opposed to asking the respondents to provide a number, which could require extra
time to look these numbers up. To provide a check on the accuracy of data collected, respondents
are also asked if their answers are based on 1) Actual court data, or 2) an educated estimate
based on reports or impressions of program staff anecdotal information. Finally, throughout the
survey, “don’t know”, “unknown or unable to answer”, or “not applicable” options are provided
for all questions. This alleviates any pressure on the respondent to be required to answer
questions that may take extra time.
A.6 CONSEQUENCES OF COLLECTING THE INFORMATION LESS FREQUENTLY
Currently, there is a major impetus to increase the use of MAT in the criminal justice system,
including drug courts. Federal funding agencies, such as the Bureau of Justice Assistance and the
Substance Abuse and Mental Health Services Administration encourage the use of MAT among
their grantees. Further, the current National Drug Control Strategy recommends the expanded
use of drug courts and diversion programs to promote entrance into treatment and making MAT
a standard of care for opioid addiction xxvi. If the proposed data collection is not conducted,
federal agencies will not know if drug courts, some of which are grantees, are adhering to these
recommendations and achieving the goal of making MAT the standard of care. Comprehensive
data about MAT use in existing drug courts are not currently collected and the most recent data
on the topic (2012) were not generalizable and collected before these initiatives were
implemented.
At this time, the survey is being proposed as a one-time data collection. However, subject to
OMB approval, it could serve as a baseline survey and conducted annually to measure the
progress of the use of MAT in drug courts. It could be modified and expanded to accommodate
other entities in the criminal justice system or different treatments for different illicit substances.

A.7 SPECIAL CIRCUMSTANCES RELATING TO THE GUIDELINES OF 5 CFR 1320
This information collection fully complies with 5 CFR 1320.5(d)(2).

A.8 COMMENTS IN RESPONSE TO THE FEDERAL REGISTER NOTICE AND
EFFORTS TO CONSULT OUTSIDE AGENCY
On October 8, 2019, a 60-Day Federal Register Notice was published at 84 FR 53762, Page:
53762 (1 page), Document Number: 2019-21921. There were no public comments received.
On December 12, 2019, a 30-Day Federal Register Notice was published at 84 FR 67964, Page:
67964 (1 page), Document Number: 2019-26803. On December 16, 2019, and error was noted in
the Notice’s contact information. The Notice was revised and resubmitted.

On December 26, 2019, a corrected 30-Day Federal Register Notice was published at 84 FR
71005, Page: 71005 (1 page), Document Number: 2019-27709. There were no public comments
received.

A.9 EXPLANATION OF ANY PAYMENT OF GIFT TO RESPONDENTS
ONDCP will not be providing gifts or incentives to respondents.
A.10 ASSURANCE OF CONFIDENTIALITY PROVIDED TO RESPONDENTS
The survey will not request the respondents’ names, social security numbers, contact information
or any other personally identifiable information (PII). The survey will request the state, county,
and zip code the respondent represents. However, the survey notes the following on the first
page:
Responses will be reported in the aggregate and will not be attributed to any
individual adult drug court.
By default, the company privacy policy of the software used to electronically administer
the survey (Cvent) is always displayed at the footer of the survey. This statement informs
respondents how their data are stored, processed, and protected by Cvent. There is also an
option for NADCP to provide a link to their privacy policy in the footer to inform
respondents. In addition to not collecting PII, Cvent will not store IP addresses that could
be used to track respondents’ location via an IP address to further ensure privacy to the
extent permitted by law.
In addition to the fact that PII will not be collected, the survey’s data and the process to
collect it are not subject to the Privacy Act. The Act “governs the collection,
maintenance, and disclosure of information from or about identifiable individuals (not
statistical or aggregate information).” The data collected from this survey will not
conduct any individual-level analyses and will be aggregated to determine overall trends
in the availability and accessibility of MAT for OUD in drug courts, policy shifts,
systematic attitudinal change, and history of training. As stated above, respondents are
informed of the aggregated data on the first page of the survey.
The NADCP/CALLC team is working with Whitworth University to obtain Institutional
Review Board (IRB) approval for the survey. The IRB process assesses the risk and
benefits to subjects in research to ensure they are protected from any harm, including
potential confidentiality breeches. It is anticipated that the survey will receive an
expedited review process. An expedited review may be used for research which involves
only procedures that involve no more than minimal risk. This review process may also be
used to review minor changes in previously approved research during the period for
which the approval is valid, and research which falls within the several exempt
categories. One of the exempt categories is: Research on individual or group

characteristics or behavior (including, but not limited to, research on perception,
cognition, motivation, identity, language, communication, cultural beliefs or practices,
and social behavior) or research employing survey, interview, oral history, focus group,
program evaluation, human factors evaluation, or quality assurance methodologies.
A.11 JUSTIFICATION FOR SENSITIVE QUESTIONS
The survey will not ask any questions that are personal or sensitive in nature. The questions only
pertain to the nature and extent of availability and accessibility of MAT for OUD in local-level
adult drug courts.
A.12 ESTIMATES OF HOUR BURDEN INCLUDING ANNUALIZED HOURLY COSTS
The estimates of hour burden are based on pilot tests of the survey with eight individuals that
averaged 15 minutes to take the survey. The estimates are below in Table A.12-1
Table A.12.1 Estimates of Hour Burden
Form Name

No. of
Respondents

Frequency of
Response

Survey on the Treatment of Opioid Use
Disorders

269

1

Average.
Burden per
Response (in
hours)
15 minutes

Total Annual
Burden (in hours)

67 hours

There is no direct cost to respondents other than their time. The annualized cost to respondents is
based on NADCP’s knowledge of local Drug Court Coordinator’s salaries (average of $60,905
per year in 2020 dollars), translated to an hourly rate. Therefore, the cost to each respondent to
take the 15-minute survey (.25 of an hour) is $7.32 per response. The annualized cost to
respondents is detailed below in Table A.12.2.

Table A.12.2 Annualized Costs to Respondents
Form Name

No. of
Frequency
Respondents of Response

Survey on
the
Treatment
of Opioid
Use
Disorders

269

1

Average
time per
Respondent
15 minutes
(.25 hours)

Annual
Hour
Burden
67 hours

Hourly
Wage Rate

Respondent
Cost

$29.28

$1,961.76

A.13 ESTIMATE OF OTHER TOTAL ANNUAL COST BURDEN TO RESPONDENTS
OR RECORD KEEPERS

There are no capital expenditures associated with this project. NADCP and CALLC are using
existing workspace, equipment, and software for this project. There are no other cost burdens to
respondents or recordkeepers.
A.14 ANNUALIZED COST TO THE FEDERAL GOVERNMENT
The budget for these activities, including costs already incurred to develop the draft survey
instrument, sampling methodology, and analysis plan is $208,825.55 over a two-year period
from January 1, 2019 to December 31, 2020.
The salary for supervision of this project by a federal government employee at ONDCP was
estimated to be approximately $174,000, with the estimation that the employee would spend
approximately 2 % of time overseeing this contract. Therefore, the cost is $3,480 per year, or
$6,960 over two years.
The total cost to the government is $215,786, which includes ONDCP employee supervision of
contract.

A.15 EXPLANATION FOR PROGRAM CHANGES OR ADJUSTMENTS
This is a new collection of information.
A.16 PLANS FOR TABULATION AND PUBLICATION AND PROJECT TIME
SCHEDULE
There are no complex analytical techniques that will be used for the survey data analyses.
Descriptive statistics and frequency distributions will be used to answer questions including:
•
•
•
•
•
•

How many adult drug courts have MAT available for their clients?
To what extent is MAT used in these courts?
What specific medications are available to drug court participants?
What are the factors that limit MAT use?
How many adult drug courts have received training that improved the delivery of MAT?
What are adult drug court practices regarding naloxone?

When applicable, answers to these questions will be compared to previous survey results.
However, due to the comprehensive nature of the proposed survey, many of the questions are
being asked of drug courts for the first time. The survey results will demonstrate if changes
in the following have occurred: accessibility and availability of MAT; factors limiting use;
circumstances where MAT is permitted; and, practitioner attitudes toward MAT. Survey
results will also be used to determine if ONDCP-funded trainings and knowledge
dissemination efforts have been effective in promoting MAT as the evidence-based standard
of care for OUD. Finally, the survey will uncover where there are gaps in knowledge and
practice so future training efforts can be modified and resources appropriately allocated.

Results from the surveys and their accompanying interpretations will be summarized in a final
report and delivered to ONDCP and distributed widely to the treatment court field. At least two
articles will be drafted and submitted to peer-reviewed journals. Specific journals have not been
finalized, but it is anticipated that submissions will be made to at least two journal types - one
public health and one criminal justice – to maximize the audience reached. The results will also
be made available on NADCP’s website, through practitioner fact sheets, email messaging, and
presentations at state, regional and national training conferences, including NADPC’s annual
conference.
A.16 - 1 PROJECT TIME SCHEDULE
Activity

Time Schedule

Notify participants of survey and send survey link
Monitor survey response activity and conduct activities to
increase response rate, if necessary
Data cleaning

1 - 30 days after OMB approval
During the 1-3 month period
after OMB approval
3 months after OMB approval

Data Analysis

During the 3-5 month period
after OMB approval
5-6 months after OMB approval

Draft final report
Presentation/dissemination of findings to ONDCP and other
stakeholders
Draft and submit journal articles to peer reviewed journals

6 months after OMB approval
7-12 months after OMB
approval

A.17 REASON(S) DISPLAY OF OMB EXPIRATION DATE IS INAPPROPRIATE
The OMB expiration date will be displayed on each instrument form.
A.18 EXCEPTIONS TO CERTIFICATION FOR PAPERWORK REDUCTION ACT
SUBMISSIONS
No exception to 5 CFR 1320.9 is sought.

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