Understanding the role of technical assistance in improving substance use disorder treatment in California: a scoping review of the literature

Introduction

Substance use and misuse have increased in the United States over the past decade, with an estimated 23% rise in the number of people using drugs (1). At the same time, the opioid overdose epidemic continues to be a significant public health concern (2). These trends present serious challenges for the field of substance use disorder (SUD) treatment, which faces persistent difficulties in delivering high-quality care due to workforce shortages, uneven implementation of evidence-based practices (EBPs), and limited sustainable funding (3).

In response, states like California have invested in technical assistance (TA) to help SUD treatment providers build infrastructure and develop a workforce capable of meeting the complex needs of clients with chronic substance use conditions (4). TA refers to the provision of targeted support tailored to an organization’s specific needs (5). Federal agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and Office of Minority Health (OMH) have funded TA initiatives to expand service capacity across healthcare systems. Since the 1970s, when the Special Action Office on Drug Abuse Prevention was established, the federal government has supported TA at state and local levels (6). TA includes a range of strategies such as facilitation, coaching, modeling, and consulting (7) and has been widely applied in addiction medicine, hospital-based care, behavioral health integration, and public health settings (8-10).

In California, TA has supported improvements in SUD treatment through initiatives that address workforce development, credentialing processes, administrative simplification, and EBP implementation (11-13). A growing body of research has found that TA contributes to better client engagement, improved access to care, and stronger treatment outcomes (14-17). Strategies such as motivational interviewing, peer support integration, client outreach, and telehealth have helped increase access and retention while reducing relapse and enhancing client functioning (14-18). TA also supports the translation of research into practice by promoting implementation strategies that align with organizational culture and client needs (19,20). Importantly, TA often focuses on serving under-resourced communities by building capacity for culturally responsive care, reducing disparities, and promoting sustainable service delivery (21,22).

Despite this progress, important gaps remain. While evidence suggests that TA can be effective, there is limited research on how it is implemented among small- and medium-sized SUD providers, particularly in diverse and resource-limited settings. There is also a lack of synthesis that connects individual TA efforts to broader systems-level strategies for building sustainable, equitable care. California’s recent needs assessments, conducted through funding from the Department of Health Care Services and coordinated by the California Association of Alcohol and Drug Program Executives (CAADPE), have surfaced key areas for improvement in culturally responsive and evidence-based care delivery. This assessment, a component of the SUD Provider Access to Resources, Knowledge, and Training (SPARK-T) Project, aimed to comprehensively understand the needs and barriers related to capacity building for treatment providers to guide development of TA delivery for the benefit of California’s SUD provider system. However, the literature has yet to fully explore how these findings translate into actionable strategies through TA.

This paper seeks to address that gap by reviewing and synthesizing existing research on the role and impact of TA in strengthening SUD treatment in California. Building on a statewide TA project and a collaborative needs assessment involving implementation researchers and SUD providers, this review aims to identify current knowledge, highlight key themes, and outline opportunities to improve the delivery and effectiveness of TA in supporting equitable, high-quality SUD treatment. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-68/rc).

Methods

The research team, comprising two doctoral-level experts in SUD treatment research and one licensed clinician and executive staff within California-based SUD treatment, followed a standard procedure for a rigorous literature review. This process included four main steps to ensure a systematic methodology. First, the team established inclusion and exclusion criteria, prioritizing peer-reviewed studies focused on improving TA and SUD treatment outcomes in the United States. Eligible studies focused on individuals with SUD or providers delivering SUD treatment and evaluated TA interventions (e.g., training, consultation, or implementation support) aimed at improving treatment outcomes. Accepted study designs included randomized controlled trials, quasi-experimental, observational, and mixed-methods studies reporting measurable outcomes like treatment engagement, retention, provider performance, or implementation fidelity. Studies were excluded if they lacked a TA component and did not report outcomes that we were interested in. Second, a comprehensive list of search (MeSH) terms was developed through discussions on key constructs: workforce development, treatment provider needs, organizational capacity, capacity building, engagement, access to care barriers, needs assessment, treatment challenges, integration of care, continuum of care, EBP, cultural competency, networking, implementation, and policy change (see Appendix 1). Third, the team conducted a systematic screening process to ensure study relevance, quality, and adherence to the inclusion criteria. This involved reviewing article abstracts and titles, followed by a detailed full-text review to evaluate fit and scope. Independent screenings were performed by the study’s three reviewers, and any discrepancies were resolved through collaborative discussion. Finally, a thematic analysis was conducted to synthesize findings across the relevant studies.

The literature search involved systematically exploring six online databases (PubMed, Web of Science, JSTOR, Science Direct, PsycINFO, and Cochrane Library) and a manual search to identify relevant articles as recommended by the PRISMA standards. All databases were searched within the same dates (start date October 5, 2024 through January 10, 2025) and use the same language restriction (English). The databases search also included the same MeSH terms (see above), as well as the same Boolean (AND/OR/NOT).

A deductive thematic analysis was used to identify recurring patterns and themes related to TA needs within selected articles. Deductive thematic analysis is a method of identifying and analyzing patterns within data based on a pre-existing theoretical framework (23). Articles were reviewed and summarized, focusing on key findings, challenges, and recommendations. Three reviewers conducted all the data extraction, search, review and analysis. For each included article, the reviewers extracted the following data: author(s), year of publication, target population (e.g., providers, clients), and key characteristics (e.g., barriers, recommendations, challenges, findings, or trends; see Table 1). These challenges and recommendations were coded into 22 recurring and overlapping topics, based on their frequency in the reviewed literature and relation to underlying theories (see Tables 2,3). From these 22 coded topics, five overarching themes were identified through a collaborative process to guide the analysis and interpretation of findings, based on thematic and conceptual similarities, recurrence across the literature, and alignment with core domains of TA application. For example, coded topics such as staff training gaps, burnout, and credentialing barriers were grouped under the theme of Workforce Development, due to their shared focus on human capital and workforce sustainability. All coding and theme development were conducted by the reviewers with subject matter expertise. Discrepancies in code grouping or theme assignment were resolved through discussion and consensus during review meetings. The 22 resulting themes then which formed the basis for analyzing the role of TA in improving SUD treatment (see Table 4): client acuity & access challenges, organizational needs, staffing challenges, treatment & training efficiency support, and workforce development. An Excel file was created to list each topic and its corresponding articles. The identification of these thematic categories helped determine the prevalence of topics in the literature and reveal patterns highlighting TA needs.

Results

The initial database and manual search yielded 85 articles. After screening abstracts, 30 articles remained. A final full-content review resulted in 18 articles that met the inclusion criteria for full consideration. The thematic analysis of these articles identified recurring challenges and recommendations related to addressing barriers in substance use treatment.

Challenges identified included limited funding and resources (11,25), workforce shortages (25,26), provider burnout (27,28), training and education gaps (16,29), client access to care issues (17,33), and variability in service quality and need based on region and demographic served (15,27), among others. Recommendations found in the literature included the need for policy changes to increase funding and resources (11,14), expanded and more accessible training and support (16,27), flexible implementation of EBPs, co-occurring treatment, and culturally competent practices (14,29), and the promotion of interdisciplinary, integrated, and community-oriented care (25,28). These inter-related challenges highlight the necessity of TA to support treatment providers at multiple levels.

Five emerging TA needs themes were identified through deductive thematic analysis: (I) client acuity & access challenges; (II) organizational needs; (III) staffing challenges; (IV) treatment & training efficiency support; and (V) workforce development (see Table 1).

Client Behavioral Health Acuteness & Access Challenges: a significant need identified in the literature is the increasing acuteness of clients presenting complex co-occurring behavioral and medical conditions, coupled with limited access to care. The coronavirus disease 2019 (COVID-19) pandemic has exacerbated these challenges, leading to greater care fragmentation and barriers to timely treatment (15,16,27,29,33). Clients frequently experience overlapping issues such as mental illness, housing instability, and involvement with the justice system, requiring coordinated and integrated services. Many small to mid-sized providers lack the necessary capacity and staffing to effectively address this complexity (11,25). TA can help address these gaps by supporting integrated care models that link behavioral health, primary care, and social services (12,20). It can also assist providers in improving triage, care coordination, and client retention, as well as promoting telehealth and flexible service delivery to overcome geographical and logistical barriers (14,15). Additionally, TA supports the implementation of culturally and linguistically appropriate services, helping organizations tailor care to diverse communities and train staff in cultural humility to reduce disparities (17,22,29).

Organizational needs

Organizational challenges underscore the critical need for TA, as many providers lack the capacity to navigate complex funding systems, comply with evolving policies, and engage in community-level change (24,27). Small to mid-sized treatment programs often struggle with fragmented funding sources, limited administrative infrastructure, and the demands of reporting and audits, which can threaten their financial stability (11,25). TA can assist organizations in developing diversified funding strategies, improving grant writing skills, and streamlining reimbursement processes, thereby reducing administrative burden and burnout (11,14). As payment models shift towards value-based care, TA supports providers in implementing data systems, tracking outcomes, and utilizing metrics for continuous quality improvement (12,33). Furthermore, TA strengthens partnerships with healthcare and community agencies, improving care coordination and expanding service capacity (27).

Staffing challenges

Persistent workforce or staffing issues, including recruitment, retention, competency gaps, and burnout, indicate an ongoing need for targeted TA to support workforce development and resilience-building strategies (11,14,25). The SUD treatment field has been particularly affected by a shortage of qualified clinicians and licensed professionals, compounded by high turnover rates and increasing job demands (25,27). This shortage limits the capacity of treatment programs to deliver timely, evidence-based care, while burnout and workplace stress further destabilize the workforce (27,28). TA can address these challenges by offering tailored workforce development initiatives that focus on recruitment pipelines, retention incentives, and training programs designed to build clinical competencies and leadership skills (16,20). Additionally, TA supports strategies to improve staff well-being through workload management, burnout prevention, and resilience training, which are critical for sustaining a competent and motivated workforce (11,14).

Treatment & training efficiency support

The need for TA is further highlighted by inefficiencies in treatment and training, particularly in adapting to emerging technologies and integrating EBPs into routine operations. As organizations strive to adopt data-driven decision-making and flexible service models, TA can play a crucial role in supporting implementation fidelity, cross disciplinary training, and service innovation (12,27,33). TA assists organizations in implementing flexible training modalities, including telehealth and hybrid options, that expand access to professional development, especially for staff in rural or underserved areas (15,33). By fostering interdisciplinary collaboration and integrated care models, TA also enhances the workforce’s capacity to meet the complex needs of clients with co-occurring disorders, thereby improving both staff satisfaction and client outcomes (14,29).

Workforce development

Key workforce development needs, including addressing educational and credentialing barriers, fostering leadership growth, and supporting staff well-being, were identified throughout the literature as essential for achieving sustainable systems change. TA provides an infrastructure through which ongoing training, mentorship, and capacity-building can be embedded within provider organizations to ensure long-term improvements in care quality and equity (7,16,20). This includes addressing workforce shortages by supporting recruitment and retention strategies tailored to the unique demands of the SUD treatment field (11,25). TA also focuses on reducing credentialing and licensing obstacles by helping organizations navigate complex regulatory environments, which is particularly important in states like California, where policies frequently evolve (12). Additionally, TA emphasizes leadership development programs that equip supervisors and managers with the skills to foster supportive work environments and drive organizational change (28). Finally, TA supports workforce resilience by providing resources and strategies to mitigate burnout and promote mental health among staff, which is essential for maintaining a motivated and effective workforce (11,27).

Discussion

The current understanding of TA’s role in SUD treatment suggests that it is a promising yet underutilized strategy for building capacity. While TA has largely focused on enhancing client engagement and the implementation of EBPs (20), opportunities remain to broaden its impact by addressing sustainability and tailoring services to underserved and minority populations (27). Given the evolving landscape of the SUD treatment field, including funding changes, increasing regulation, and a workforce crisis, especially in California, this literature review indicates that efforts should prioritize strengthening workforce development (33), enhancing funding mechanisms (16), and improving the integration of care across services (34). Ongoing and emerging trends in substance use and its co-occurring consequences present complex challenges for California’s behavioral health system, particularly for small to mid-sized treatment providers that often operate with limited resources and serve highly vulnerable populations. This review supports the growing consensus in the literature that TA, in its various forms and approaches, is a critical mechanism for building capacity, improving service delivery, and advancing workforce development within the SUD treatment field. The findings underscore that TA, when implemented systematically and tailored to local contexts, can effectively address provider-level barriers such as burnout, training deficiencies, and administrative burdens, while also fostering broader organizational change and the integration of EBPs. In California, where disparities in access, regional variability in provider capacity, and evolving policy demands compound existing challenges, TA offers a promising avenue for targeted, sustainable intervention. As the state continues to invest in behavioral health infrastructure, actionable strategies to enhance access to quality care may include integrating a robust, equity-informed TA framework into its strategic planning to foster a more resilient and responsive treatment system. Ongoing evaluation and adaptation of TA efforts will be critical to ensure that these supports lead to measurable improvements in workforce stability, service quality, and health outcomes for individuals affected by substance use. Considering the current knowledge of TA in California, TA efforts could be maximized in areas of capacity building, workforce development, client engagement, and training. Supporting initiatives like the SPARK-T led by CAADPE, which provide training and capacity-building resources to enhance service delivery and sustainability for small and medium-sized programs, is crucial (4). Ultimately, expanding TA in staffing and capacity-building will enhance the effectiveness of the EBPs that these programs currently deliver.

Conclusions

This scoping review highlights TA as a critical mechanism for strengthening SUD treatment systems through workforce development, organizational capacity building, and integrated care approaches. Evidence indicates that tailored and equity-informed TA frameworks can help address persistent barriers such as workforce shortages, funding instability, and training gaps, particularly among small and mid-sized providers in California. Continued investment in and evaluation of TA initiatives will be essential to advancing sustainable, high-quality, and culturally responsive SUD care across the state.

Acknowledgments

The authors acknowledge the support from funders and administrators, as well as coaches from SUD treatment providers who partnered in this effort. The authors extend their sincere gratitude to the agency leaders and their implementation staff who contributed to the different phases of the SPARK-T Project.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-68/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-68/prf

Funding: This project was funded by the California Department of Healthcare Services and administered by the California Association of Alcohol and Drug Program Executives (CAADPE), as part of the SPARK-T Project. The Department of Health Care Services (DHCS) had no role in the planning or execution of this literature review; in the writing of the manuscript; or in the decision to submit the manuscript for publication.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-68/coif). E.G.G. serves as an unpaid editorial board member of Journal of Hospital Management and Health Policy from October 2025 to September 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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