Table 4.

Select facilitators of substance use care for justice-involved youth and illustrative quotes

COM-B Domain	Sub-Theme	Quotes
Psychological Capability	SUD training for all team members	Training for staff, training for nurses, training for juvenile probation officers has to be part of it.
	Knowledge of adolescent development	The need to have an Adolescent Medicine specialist was really important to us. Most juvenile detention centers are under the supervision of Adolescent just because of the extra training with the population.
	Training in communication with youth	I do think that strength-based scripts for providers to practice. The difference between, "Do you drink?" versus, "How much would you say you drink, if any?" That kind of scripting.
	Comfort with motivational interviewing	I think another thing that is an underutilized tool that’s a lot easier to initiate is motivational interviewing based stuff.
	Trauma-sensitive approaches	Make sure that everybody is trauma-trained. Trauma, affect regulation, and substance use are the three legged stool.
	Addressing drivers of substance use	I think one of the things to recognize is the large number of dual diagnoses. And that managing the depression, the anxiety, the PTSD symptoms, all of that, really needs to be part of understanding substance use treatment.
Reflective Motivation	Staff empowerment	Anybody should be able to write the substance use assessment, do the intake, all that sort of thing…now it's not really an issue because it's just what we do. Everybody knows the language and the young people know the language.
	MOUD as standard of care	There's no excuse anymore. Juvenile and adult correctional facilities should be offering medication-assisted- treatment or medication-based treatment. There should be no more excuses.
Automatic Motivation	Institutional culture	So sometimes it's the culture of the facility, sometimes you have to move that slowly on the spectrum to where you want to get it to match best practices. And that takes, you know, kind of education of everybody.
	Leadership support	The biggest factor that sets that tone is the leader of the institution. Having leadership that's vocally supportive of the substance use program, that is also anti-racist and setting a tone that makes it a positive work environment.
	Addressing fears and stigma	I've had to have conversations with staff - I'm thinking of one staff member who is a recovering addict themself and they are biased that replacing one substance with another is not true recovery.
Physical Opportunity	Standardized protocols	I think it has to be in written into the forms or electronic medical record that you're using. You've got to have standard questions that you think you want to ask and you ask everyone.
	Staff availability	You know, it's really good to have 24/7 nursing coverage. To really do this work, and not put certain kids in the hospital, you really do have to have 24/7 nursing coverage.
	Securing funding	Be thinking in terms of the clinical outcomes. You get the programming, you get the money, that's awesome. You've got to be able to demonstrate the usage and the efficacy. Be thoughtful at the beginning to make sure you get what you need.
Social Opportunity	Honoring youth autonomy	Seven Challenges really empowers young people. I'm not here to get you to quit using drugs. That's not my job. My job is to really help you think things through. And help you be successful with whatever that might be for you.
	Strengths-based interviewing	Staff are all very well-trained in strength-based approaches to motivational interviewing. Really understanding what healing-centered approaches mean and how to bring that kind of more healing and recovery focus to it.
	Harm reduction approach to care	It’s about the risk reduction, which is a really different way of thinking about substance use treatment rather than saying: don't use it and if you use it, you're bad. Instead, let's talk about what change might look like.
	Incorporating family	When they leave and they go home, their family is a big piece of things. If you haven't included the families early on, that tends to not go as well. If the kid is okay with you enlisting the help of the parents, that can be really huge.
	Standardized discharge process	We do a youth centered reentry team (YCRT) meeting for every youth that comes in. At entry, we're getting ready for exit and getting after-care release plans for that youth to find out what they need. They all have that YCRT plan ready to go.
	Continuity of care	We've been trying for a while now to set up so that our clinicians can keep working with kids after they leave. A number of youth said yeah, they would like to do that if they could. They've connected with people here.