Table 3.

Key barriers to substance use care for justice-involved youth and illustrative quotes

COM-B Domain	Sub-Theme	Quotes
Psychological Capability	Inadequate SUD-specific training	Getting all of our clinicians appropriately waivered was step one. My hope had been that we would actually get to a place where we could do induction at the detention facility. But that also meant getting our nurses trained, and so on.
	Lack of MOUD knowledge	Lack of training for providers is a barrier. So we have talked about Buprenorphine training as a program but we haven't been able to get something like that coordinated because we are a small program.
	Variable provider comfort	Total volume is low, so it’s hard for providers to gain any comfort with bupe. Like, you need to be very comfortable using those medications, sending people out with Naloxone, that kind of thing.
	Limited behavioral health resources	We don't have any in-house mental health support - period. Much less substance use counseling. It really is the resource issue.
Physical Capability	Threats to youth safety	We ran into all kinds of safety issues.
	Influence of home environment	Since they’re kids, they go back to where they came from by and large. So in some cases, many cases, they're going back into the very situations that generated problems.
Reflective Motivation	Negative beliefs about SUD	Views on substance use are almost like political views. You know what I mean? So they can be set in their ways. It doesn't matter what kind of evidence you provide them.
	Negative beliefs about MOUD	And so what can happen depending on your nursing staff, your behavioral health staff, is almost how much they believe in the necessity of medication assisted treatment, they may or may not bring certain kids to your attention.
	Poor staff receptivity	I think we have faced what everybody faces, right? That, I'm gonna identify it, but then I don't have anything to give, and I don't have anybody to connect them to, and so I'm not gonna work so hard to identify it.
Automatic Motivation	Unsupportive leadership	If you're in a state agency, you also have to have your top management in agreement with what you're doing.
	Stigma	There can be biases against the kids that have really significant opioid use disorders. And again, changing that culture of the facility so that the staff aren't thinking in their minds "it's just a junky."
	Fear of diversion	The other barrier is removing that concern for contraband. I think Suboxone just has a bad rap, you know, because it's used in contraband in a lot in prisons…. I'm trying to remove the need for contraband because we're offering treatment.
Physical Opportunity	Inadequate time	There were so many people that just didn't want to do it, because it's another thing. And intakes take so long.
	Staffing shortages	The main barrier is person power. In any given time, you know, there's a certain number of vacancies in our system across the board and it is hard to get people into some of the positions.
	Insufficient funding	Lack of funding to support SUD treatment. I'm sure that funding is a problem.
	Lack of protocols	We would like to start it, but we actually have to have some sort of protocols in place.
	Difficulty stocking medications on-site	If you're gonna store a CDS, like buprenorphine is, you have to have a CDS registration and a DEA registration for the facility. Not just for the provider, but for the facility. And that is not an easy process to do.
	COVID	I would say that COVID has put a damper on anything because, with quarantine, kids can't interact with anybody. So as the precautions, hopefully, continue to lift, I think that we will have more opportunity to actually work with the kids.
Social Opportunity	Youth reticence to disclose substance use	I think it's hard because when we do our intakes, kids are hesitant to disclose substance use because of where they are.
	Youth ambivalence	Sometimes youth interest in treatment is not, you know, they are not there yet.
	Lack of community substance use resources	There are very few pediatric substance abuse services, right? And even fewer that insurance covers. Which is a problem.
	Difficulty continuing medications post-release	There's not great adolescent outpatient MAT available. That level of discontinuity of care is the biggest challenge for us.