Partnership To End Addiction

FAMILY-BASED RECOVERY SUPPORT SERVICE NETWORK FOR YOUTH OUD

WAKE UP TO MEDICINE ABUSE

NEW YORK STATE HEALTH HOME IMPACT ON HIV TREATMENT CASCADE

DISEASE MANAGEMENT FOR CHRONIC DRUG ABUSE

THE IMPACT OF HEALTH HOMES IN NEW YORK STATE ON PEOPLE WITH SUBSTANCE USE DISORDE

TAILORED ADAPTIVE MOBILE MESSAGING TO REDUCE PROBLEM DRINKING

QUALITY COMMUNITY SERVICES FOR ADOLESCENT DRUG ABUSE

RESTRUCTURING SERVICES FOR DRUG ABUSING TANF WOMEN

LOCAL QUALITY ASSURANCE TOOL FOR FAMILY THERAPY IN USUAL CARE FOR ADOLESCENT SUBSTANCE USE

DEVELOPING A SCREENING AND BRIEF INTERVENTION PACKAGE TO ADDRESS SUBSTANCE USE RISK IN PREGNANT AND POSTPARTUM WOMEN IN HOME VISITING PROGRAMS

EVIDENCE-BASED PRACTICES AND SERVICE OUTCOMES IN USUAL CARE FOR ASA

FIDELITY TRAINING AND FEEDBACK SYSTEM FOR ADOLESCENT EXTERNALIZING PROBLEMS

TESTING A SYSTEM-LEVEL IMPLEMENTATION INTERVENTION TO IMPROVE THE QUALITY OF FAMILY-BASED SERVICES FOR ADOLESCENT SUBSTANCE USE

TESTING THE FEASIBILITY OF A FAMILY-BASED ADJUNCTIVE TREATMENT PROTOCOL FOR TARGETING CO-OCCURRING INTERNALIZING DISORDERS AMONG ADOLESCENTS WITH SUD - PROJECT SUMMARY (ABSTRACT) THIS R34 WILL DEVELOP AND TEST AN ADJUNCTIVE TREATMENT PROTOCOL FOR ADDRESSING CO-OCCURRING INTERNALIZING DISORDERS AMONG ADOLESCENTS (AGE 13-21) ENROLLED IN USUAL CARE FOR SUBSTANCE USE PROBLEMS. INTERNALIZING DISORDERS (IDS), PRIMARILY DEPRESSION AND ANXIETY, ARE HIGHLY PREVALENT AMONG YOUTH RECEIVING COMMUNITY-BASED TREATMENT FOR SUBSTANCE USE DISORDERS (SUDS), AND UNRESOLVED ID ISSUES SIGNIFICANTLY INTERFERE WITH SUD TREATMENT AND RECOVERY PROCESSES. YET, THE YOUTH SUD CLINICAL WORKFORCE IS NOT SYSTEMATICALLY EDUCATED OR TRAINED IN EVIDENCE-BASED PRACTICES FOR ID; THUS, LINE SERVICES FOR YOUTH SUD DO NOT SYSTEMATICALLY TARGET IDS. THE RESEARCH LITERATURE OFFERS A FEW INTEGRATED BEHAVIORAL MODELS FOR SIMULTANEOUSLY TREATING BOTH SUDS AND IDS IN YOUTH; HOWEVER, SUCH MODELS FEATURE INTENSIVE MANUALIZED PROCEDURES THAT HAVE PROVEN CUMBERSOME TO SCALE AND DELIVER IN FRONTLINE SETTINGS. AS A RESULT, THE CLINICAL WORKFORCE, THOUGH DESIRING ID-FOCUSED TRAINING, CURRENTLY HAS INADEQUATE RESOURCES FOR TREATING IDS EFFECTIVELY. A PROMISING SOLUTION TO REDUCE THIS QUALITY GAP IS DEVELOPING A MODULAR, FAMILY-BASED PROTOCOL TO AUGMENT ROUTINE CARE FOR COMORBID SUD/ID BY DIRECTLY TARGETING ID AS A PRIMARY TREATMENT GOAL: FAMILY SUPPORT PROTOCOL FOR ADOLESCENT INTERNALIZING DISORDERS (FAM-AID). FAM-AID WILL CONTAIN SIX MODULES DESIGNED TO ENHANCE EXISTING SUD SERVICES AND TO BE DELIVERED IN ANY SEQUENCE TO MEET CLIENT NEEDS: (1) FAMILY ENGAGEMENT OF CAREGIVERS IN TREATMENT PLANNING AND SERVICES; (2) RELATIONAL REFRAMING OF FAMILY CONSTRAINTS, RESILIENCIES, AND SOCIAL CAPITAL CONNECTED TO THE YOUTH'S ID SYMPTOMS; (3) FUNCTIONAL ANALYSIS OF THE YOUTH'S ID SYMPTOMS AND RELATED BEHAVIORS; (4) CORE COGNITIVE-BEHAVIORAL TREATMENT TECHNIQUES TO ADDRESS THE YOUTH'S ID SYMPTOMS AND FUNCTIONAL NEEDS, FEATURING TRANSDIAGNOSTIC INTERVENTIONS (EMOTION ACCEPTANCE, EMOTIONAL EXPOSURE, BEHAVIORAL ACTIVATION) TO ADDRESS NEGATIVE AFFECT AND EMOTIONAL DYSREGULATION UNDERLYING BOTH DEPRESSION AND ANXIETY; (5) FAMILY PSYCHOEDUCATION AND SAFETY PLANNING FOCUSED ON EDUCATION ABOUT COMORBID SUD/ID AND PREVENTION OF YOUTH SELF-HARM. THE STUDY WILL FOLLOW THE NIDA BLUEPRINT FOR STAGE 1 DEVELOPMENT OF BEHAVIORAL PROTOCOLS. IN THE PILOT STAGE WE WILL USE RAPID CYCLE PROTOTYPING METHODS IN COLLABORATION WITH END-USER STAKEHOLDERS AT TWO PILOT SITES TO: (1) DRAFT PROTOCOL DELIVERY AND FIDELITY GUIDELINES ADAPTED FROM EXISTING STUDY TEAM RESOURCES; (2) SOLICIT CLINIC STAFF AND CLIENT INPUT ON PROTOCOL CONTENT AND DELIVERY VIA COGNITIVE INTERVIEWING; (3) PILOT THE PROTOTYPE COMPONENTS ON 2-3 CASES AT EACH SITE. WE WILL THEN CONDUCT AN INTERRUPTED TIME SERIES STUDY FOR N = 60 COMORBID SUD/ID CASES ACROSS TWO SITES SERVING DIVERSE YOUTH: 30 WILL RECEIVE TAU (HISTORICAL CONTROL), AND THEN FOLLOWING LINE STAFF TRAINING IN THE PROTOCOL, 30 NEW CASES WILL RECEIVE TAU ENHANCED BY FAM- AID. AIM 1 WILL EXAMINE FAM-AID CASES FOR PROTOCOL ACCEPTABILITY VIA THERAPIST AND CLIENT INTERVIEWS AND FIDELITY BENCHMARKS VIA THERAPIST- AND OBSERVER-REPORT PROTOCOL FIDELITY DATA. AIM 2 WILL COMPARE FAM-AID VERSUS TAU FOR IMMEDIATE OUTCOMES ON FAMILY ATTENDANCE IN SESSIONS AND ULTIMATE OUTCOMES ON YOUTH ID SYMPTOMS AT BASELINE, 3-, AND 6-MONTH FOLLOW-UP.

ADAPTIVE TEXT MESSAGING INTERVENTION FOR RISKY DRINKING IN POSTPARTUM WOMEN

INTEGRATED FAMILY-BASED TREATMENT OF CO-OCCURRING ADOLESCENT SUD AND ADHD

DIGITAL SCREENING AND BRIEF INTERVENTION FOR PERINATAL SUBSTANCE USE IN HOME VISITING - ABSTRACT THE EARLY POSTPARTUM PERIOD IS A TIME OF SIGNIFICANT RISK FOR ESCALATING SUBSTANCE USE (SU), AS MANY PEOPLE WHO REDUCE THEIR SU DURING PREGNANCY RETURN TO PRE-PREGNANCY LEVELS WITHIN 3 MONTHS POSTPARTUM. ADDRESSING POSTPARTUM SU IS KEY TO PREVENTING NEGATIVE MATERNAL AND CHILD HEALTH OUTCOMES, BUT POSTPARTUM MOTHERS ARE UNLIKELY TO SEEK TREATMENT FOR SU, DUE TO STIGMA AND FEAR OF CHILD REMOVAL. HOME VISITING (HV), A NATIONALLY AVAILABLE VOLUNTARY SUPPORTIVE INTERVENTION FOR HIGH-RISK FAMILIES DURING THE PERINATAL PERIOD, IS A PROMISING VENUE FOR REACHING NEW MOTHERS TO PREVENT SU, AS IT IS OFTEN ONE OF THE ONLY SERVICE TOUCHPOINTS FOR VULNERABLE FAMILIES DURING THE POSTPARTUM PERIOD. HOWEVER, MOST WIDELY USED HV MODELS DO NOT HAVE STANDARDIZED PROTOCOLS FOR IDENTIFYING AND ADDRESSING SU RISK. OUR TEAM ADAPTED AN ELECTRONIC SCREENING AND BRIEF INTERVENTION (E-SBI) FOR SU AND TAILORED IT TO THE HV CONTEXT (SBI-HV). THE SBI-HV INCLUDED AN E-SBI COMPLETED BY HV CLIENTS CONFIDENTIALLY IN BETWEEN HOME VISITS, AND A HOME VISITOR FACILITATION COMPONENT TO SUPPORT INTEGRATION OF THE E- SBI INTO ROUTINE HV. A PRIOR STUDY DEMONSTRATED PRELIMINARY FEASIBILITY AND ACCEPTABILITY OF SBI-HV. THE PROPOSED STUDY AIMS TO FURTHER OPTIMIZE THE SBI-HV BY APPLYING A FACTORIAL DESIGN TO EXAMINE PRELIMINARY IMPACTS OF THREE SBI DELIVERY STRATEGIES: A SINGLE E-SBI SESSION (MAIN E-SBI), THE MAIN E-SBI PLUS A BOOSTER SESSION (BOOSTER E- SBI), AND 4 WEEKS OF TAILORED TEXT MESSAGING FOLLOWING E-SBI. ADDITIONALLY, WE WILL SYSTEMATICALLY ASSESS IMPLEMENTATION FACILITATORS AND BARRIERS TO INFORM DEVELOPMENT OF TARGETED IMPLEMENTATION STRATEGIES TO SUPPORT SUSTAINABLE INTEGRATION OF SBI-HV INTO ROUTINE HV. THE PROPOSED R34 WILL USE A TYPE 1 HYBRID IMPLEMENTATION- EFFECTIVENESS DESIGN WITH A PILOT 3X2 FACTORIAL TRIAL AND APPLY THE RE-AIM AND PRISM IMPLEMENTATION FRAMEWORKS TO ACHIEVE THE FOLLOWING SPECIFIC AIMS: (1) TEST THE IMPACT OF 3 SBI-HV DELIVERY STRATEGIES (MAIN E-SBI; MAIN E- SBI + BOOSTER; TEXT MESSAGING) ON POSTPARTUM SU, MATERNAL SELF-EFFICACY, MOTIVATION TO AVOID SU, AND HV RETENTION; (2) EVALUATE FEASIBILITY, ACCEPTABILITY, FIDELITY, AND FACILITATORS AND BARRIERS TO THE SBI-HV DELIVERY STRATEGIES; AND (3) DEVELOP TAILORED IMPLEMENTATION STRATEGIES TO SUPPORT SBI-HV INTEGRATION INTO ROUTINE HV. WE WILL PARTNER WITH THE KANSAS HEALTHY FAMILIES (HF) MULTI-SITE HV SYSTEM TO COMPLETE STUDY AIMS IN 3 PHASES. THE PRE-IMPLEMENTATION PHASE WILL INCLUDE A MIXED-METHODS ASSESSMENT OF PRISM DOMAINS AIMED AT SELECTING IMPLEMENTATION PROGRAM SITES, PROMOTING BUY-IN FROM KEY STAFF, AND INFORMING LOCAL ADAPTATIONS TO THE SBI-HV. THE IMPLEMENTATION PHASE WILL INCLUDE A PILOT 3X2 FACTORIAL TRIAL WITH 120 CLIENTS AND 20 HOME VISITORS AT 5 SITES TO OBTAIN PROOF-OF-CONCEPT DATA ON THE INDIVIDUAL AND COMBINED IMPACTS OF THE SBI-HV DELIVERY STRATEGIES. THE POST-IMPLEMENTATION PHASE WILL INCLUDE QUALITATIVE INTERVIEWS WITH FACTORIAL TRIAL PARTICIPANTS AND HV STAFF TO ASSESS IMPLEMENTATION FACILITATORS AND BARRIERS, FOLLOWED BY AN ITERATIVE STAKEHOLDER-ENGAGED PROCESS OF DEVELOPING CANDIDATE IMPLEMENTATION STRATEGIES FOR FUTURE TESTING. STUDY RESULTS WILL INFORM THE DESIGN OF A FUTURE TYPE 2 HYBRID TRIAL TO FURTHER OPTIMIZE SBI-HV AND RIGOROUSLY EVALUATE COMPANION IMPLEMENTATION STRATEGIES.

HELPLINE DELIVERY OF BRIEF INTERVENTIONS FOR POSTPARTUM HEAVY EPISODIC DRINKING - ABSTRACT THE PROPOSED R34 WILL DEVELOP AND TEST DIGITAL HELPLINE INTERVENTION COMPONENTS AIMED AT REDUCING HEAVY EPISODIC DRINKING (HED) DURING THE FIRST 3 MONTHS POSTPARTUM. HED IS PREVALENT AMONG WOMEN OF REPRODUCTIVE AGE, AND MORE THAN HALF OF WOMEN WHO REDUCE THEIR DRINKING DURING PREGNANCY RETURN TO PRE-PREGNANCY LEVELS WITHIN 3 MONTHS POSTPARTUM, MAKING THIS A CRITICAL TIME FOR INTERVENTION. ADDRESSING POSTPARTUM HED IS KEY TO PREVENTING NEGATIVE MATERNAL AND CHILD HEALTH OUTCOMES, INCLUDING FETAL ALCOHOL SPECTRUM DISORDER IN SUBSEQUENT PREGNANCIES. POSTPARTUM MOTHERS ARE UNLIKELY TO SEEK TREATMENT FOR HED, DUE TO STIGMA AND FEAR OF CHILD REMOVAL. HELPLINES THAT USE REAL-TIME SYNCHRONOUS TEXT WITH A PROFESSIONAL, AS WELL AS AUTOMATED MESSAGING, ARE A PROMISING MECHANISM FOR REACHING POSTPARTUM MOTHERS TO DELIVER EFFECTIVE BRIEF INTERVENTIONS FOR HED, AS THEY ARE WIDELY ACCESSIBLE, CONVENIENT, FREE, AND ANONYMOUS. THE PROPOSED STUDY WILL APPLY THE MULTIPHASE OPTIMIZATION STRATEGY (MOST) FRAMEWORK TO DEVELOP STANDARD HELPLINE INTERVENTIONS (ASSESSMENT, PSYCHOEDUCATION, AND LINKS TO RESOURCES), AND EVIDENCE-BASED BRIEF INTERVENTIONS FOR ALCOHOL USE (MOTIVATIONAL INTERVIEWING AND COPING SKILLS TRAINING), ALL TAILORED TO THE POSTPARTUM PERIOD AND DELIVERED VIA SCHEDULED SESSIONS OF SYNCHRONOUS TEXTING WITH A HELPLINE SPECIALIST. THE STANDARD HELPLINE COMPONENT WILL ALSO INCLUDE THE ASYNCHRONOUS SUPPORT TYPICAL OF HELPLINES. FOLLOWING DEVELOPMENT, A PILOT FACTORIAL TRIAL WILL EVALUATE THE STANDARD HELPLINE INTERVENTIONS FOR THIS UNIQUE POPULATION, EXAMINE THE FEASIBILITY AND ADDED VALUE OF EVIDENCE- BASED BRIEF INTERVENTIONS DELIVERED VIA HELPLINE, AND ASSESS THE ADDED IMPACT OF 4 WEEKS OF AUTOMATED MESSAGES TO PROVIDE ONGOING REINFORCEMENT OF INTERVENTION CONTENT. SPECIFIC AIMS ARE TO (1) DEVELOP INTERVENTION COMPONENTS, HELPLINE STAFF TRAINING, AND FIDELITY MONITORING PROTOCOLS VIA AN ITERATIVE USER-CENTERED DESIGN PROCESS WITH 15 MOTHERS, 5 HELPLINE SPECIALISTS, AND AN EXPERT PANEL; AND (2) CONDUCT A PILOT 2X2X2 FACTORIAL TRIAL WITH 120 NEW MOTHERS TO ASSESS FEASIBILITY, ACCEPTABILITY, AND FIDELITY OF EACH INTERVENTION COMPONENT, AND OBTAIN PRELIMINARY PROOF-OF-CONCEPT EFFECTS OF INTERVENTION COMPONENTS ON PROXIMAL (MOTIVATION, SELF-EFFICACY, AND SELF-REGULATION) AND DISTAL (QUANTITY AND FREQUENCY OF HED) OUTCOMES TO PREPARE FOR A FUTURE FULLY-POWERED OPTIMIZATION TRIAL. STUDY PRODUCTS WILL BE A SET OF PILOTED INTERVENTION COMPONENTS FOR DELIVERY VIA DIGITAL HELPLINE, READY FOR OPTIMIZATION AND EVALUATION IN AN R01. PARTNERSHIP TO END ADDICTION’S EXISTING HELPLINE INFRASTRUCTURE WILL SUPPORT FUTURE TESTING AND ULTIMATE SCALABILITY.

TREATING ADDICTION AS A CHRONIC ILLNESS

OPTIMIZING A DIGITAL SUPPORT SERVICE FOR CONCERNED SIGNIFICANT OTHERS OF INDIVIDUALS WITH SUD WITH HELPLINE, AI-ENHANCED AND PEER-LED SUPPORT - PROJECT ABSTRACT FAMILIES OF INDIVIDUALS WITH SUBSTANCE USE DISORDER (SUD) EXPERIENCE HIGH LEVELS OF DISTRESS AND LIMITED ACCESS TO EVIDENCE-BASED SUPPORT. CONCERNED SIGNIFICANT OTHERS (CSOS), PARTICULARLY PARENTS AND CAREGIVERS, OFTEN STRUGGLE TO NAVIGATE THEIR LOVED ONE'S (LO) SUBSTANCE USE AND TREATMENT OPTIONS DUE TO STIGMA, FINANCIAL BARRIERS, AND SYSTEMIC EXCLUSION FROM CARE. WHILE FAMILY INVOLVEMENT IMPROVES TREATMENT ENGAGEMENT AND RECOVERY OUTCOMES, FEW SCALABLE INTERVENTIONS EXIST TO PROVIDE STRUCTURED, ONGOING SUPPORT TO CSOS. DIGITAL INTERVENTIONS, INCLUDING AI-DRIVEN CHATBOTS, HAVE THE POTENTIAL TO INCREASE ACCESSIBILITY AND ENGAGEMENT; HOWEVER, NO AI-BASED MODELS ARE CURRENTLY DESIGNED TO DELIVER TAILORED, EVIDENCE-BASED SUPPORT TO CSOS. THIS R61/R33 STUDY WILL DEVELOP AND EVALUATE HALO (HELPING AFFECTED LOVED ONES), AN AI-POWERED CHATBOT DESIGNED TO PROVIDE REAL-TIME, STRUCTURED GUIDANCE TO CSOS WITHIN A DIGITAL FAMILY SUPPORT ECOSYSTEM. HALO WILL BE INTEGRATED INTO THE PARTNERSHIP TO END ADDICTION'S HELPLINE, WHICH SERVES OVER 23,000 FAMILIES ANNUALLY THROUGH PHONE, TEXT, AUTOMATED MESSAGING, PEER SUPPORT, AND E-LEARNING. IN THE R61 PHASE, WE WILL APPLY NATURAL LANGUAGE PROCESSING (NLP) TECHNIQUES TO ANALYZE 40,000+ HELPLINE INTERACTIONS, CONDUCT SURVEYS AND INTERVIEWS WITH CSOS, LOS, AND PEER COACHES, AND USE A USER-CENTERED DESIGN APPROACH TO DEVELOP HALO. A THREE-MONTH PILOT TRIAL (N=60) WILL ASSESS FEASIBILITY, USABILITY, ENGAGEMENT, AND PRELIMINARY EFFECTS ON FAMILY RECOVERY CAPITAL, CSO FUNCTIONING, AND LO SUBSTANCE USE ACROSS THREE CONDITIONS: (1) HELPLINE (HL) ONLY; (2) HL + HALO; AND (3) HL + HALO + PEER SUPPORT (PS). MEETING PREDEFINED FEASIBILITY BENCHMARKS WILL DETERMINE PROGRESSION TO THE R33 PHASE, WHERE WE WILL CONDUCT A SIX-MONTH, 2X2 FACTORIAL TRIAL (N=800) TO EVALUATE THE INDIVIDUAL AND COMBINED EFFECTS OF HELPLINE, HALO, AND PS ON CSO AND LO OUTCOMES. A SUB-SAMPLE OF 200 LOS WILL BE ASSESSED AT THREE MONTHS TO EXAMINE THE EXPERIENCES AND PERCEPTIONS OF LOS AND THEIR RELATIONSHIP WITH CSOS ON THEIR RECOVERY. THIS STUDY WILL PROVIDE THE FIRST RIGOROUSLY TESTED AI-HUMAN HYBRID SUPPORT MODEL FOR CSOS AND GENERATE DATA ON THE COMPARATIVE AND COMBINED EFFECTS OF AI-DRIVEN AND PEER- BASED SUPPORT INTERVENTIONS IN A REPRESENTATIVE GROUP OF CSOS WITH DIFFERENT NEEDS. FINDINGS WILL EXPAND REAL- WORLD TOOLS FOR CSOS BY INTEGRATING HALO INTO THE PARTNERSHIP'S FREE DIGITAL SUPPORT ECOSYSTEM AND MAKING IT AVAILABLE TO TREATMENT AND COMMUNITY-BASED SERVICES THAT LACK FORMAL FAMILY SUPPORT INTERVENTIONS.

FAMILY-BASED PROTOCOL FOR MEDICATION INTEGRATION IN TREATMENT OF COMORBID ASU/ADH

ENHANCING EVIDENCE BASED HOME VISITING TO ADDRESS SUBSTANCE ABUSE AND MENTAL HEAL

FY 2023 CONGRESSIOANAL DIRECTIVE SPENDING PROJECTS: FOR TELEHEALTH AND MOBILE BEHAVIORAL HEALTH SERVICES, OUTREACH, AND AWARENESS ACTIVITIES. - WE WILL BEGIN OUR PROJECT WITH AN ASSESSMENT OF THE NEEDS AND PERSPECTIVES OF BLACK COMMUNITY MEMBERS IN NYS, ALLOWING US TO DETERMINE HOW OUR FAMILY SUPPORT AND EDUCATIONAL RESOURCES CAN BETTER SERVE THEIR NEEDS. TO CONDUCT THIS ASSESSMENT, WE WILL COLLABORATE WITH ORGANIZATIONS PROVIDING DIRECT SUD, BEHAVIORAL HEALTH AND OTHER SERVICES TO THE BLACK COMMUNITY: COMMUNITY-BASED ORGANIZATIONS, FAITH-BASED ORGANIZATIONS, MENTAL HEALTH ORGANIZATIONS, AND ORGANIZATIONS COMMITTED TO HARM REDUCTION. THE KNOWLEDGE WE GAIN WILL BE USED TO ADAPT OUR MARKETING MATERIALS, TO RETHINK OUR MARKETING STRATEGIES, AND TO ENHANCE THE CULTURAL COMPETENCIES OF OUR SERVICES AND EDUCATIONAL MATERIALS. BY INCREASING ACCESS TO OUR INFORMATION AND SUPPORT AND MAKING IT MOST EFFECTIVE FOR THEIR NEEDS, WE HOPE THAT BLACK FAMILIES WILL BE ABLE TO HELP THEIR CHILDREN PREVENT, TREAT OR RECOVER FROM ADDICTION AND REDUCE SUBSTANCE-RELATED HARMS. LEARNING WILL BE DISSEMINATED TO IMPROVE OUTCOMES FOR ORGANIZATIONS BEYOND THE PARTNERSHIP.

COACHING PERFORMANCE DRIVEN PRACTICE CHANGE IN THE CONTEXT OF VALUE BASED PURCHASING UNDER NEW YORK MEDICAID

THE IMPACT OF HEALTH HOMES IN NEW YORK STATE ON PEOPLE WITH SUBSTANCE USE DISORDE

CASACONFERENCE, HIGH SOCIETY: SUBSTANCE ABUSE AND PUBLIC POLICY