NIATx: The Intersection of Behavioral Health and Systems Engineering — A Conversation with David H. Gustafson

By David H. Gustafson, PhD, Director, Center for Health Enhancement Systems Studies, and Maureen Fitzgerald, Communications Manager, Great Lakes ATTC, MHTTC, and PTTC

Update: In Memoriam

It is with deep sadness that we acknowledge the passing of Don Holloway, who made significant contributions to the NIATx model. 

Learn more about Don’s legacy.

Dave Gustafson

Dave Gustafson directs the University of Wisconsin−Madison’s Center for Health Enhancement Systems Studies, which includes the Great Lakes ATTC, MHTTC, PTTC, NIATx, and several research projects that focus on using systems engineering tools to support sustainable individual and organizational improvement. His individual and systems change research develops and tests technology to help people deal with issues affecting quality of life, including addiction, cancer, and aging.

In this post, Dave reflects on the enduring impact of the NIATx model.

When NIATx launched in 2003, did you envision it expanding and continuing to grow 20 years later?

Photo of David Gustafson, PhD
"No, it was not a long-term view at all. The Robert Wood Johnson Foundation (RWJF) was interested in whether systems engineering could help in the addiction space. Victor Capoccia, a project officer with RWJF, contacted me and asked if I wanted to run a national program focused on improving addiction treatment. I knew nothing about addiction treatment, so I played the role of someone with an SUD and tried to get myself admitted for treatment in a couple of places. I wanted to make sure that the program we set up with RWJF would make a difference. Our vision was very short-term — what we could do in the 3 or 4 years of the funding period. We did not expect the project to have an extended life beyond the initial funding in 2003.”

What was something that surprised you in the NIATx evolution?

“The biggest surprise was recognizing how little I knew about what it takes for your work to have a broad impact. Victor Capoccia was always thinking about NIATx at a much broader level and set the direction for us. He'd call me and say, "OK, I've set up a meeting with Congress so we can talk about this," or, "I think we can hold a national conference."

Other things came up, but I wouldn’t refer to them as surprises—more like accidental discoveries. Some of the changes we made came about just from conversations. One that stands out is a conversation I had with Dean Lea, one of our NIATx coaches for the first project. Dean and I were driving back from a visit to a treatment center in Maine that Lynn Madden (a current NIATx coach) was directing. We’d been looking at appointment books from a lot of agencies and could see from the packed schedules that there was no room for new patients. But we could also see how many appointments were canceled or no-shows. While the field as a whole was saying they could not meet demand, agencies often had 35% unused space. Dean said, "I don't know why people even bother to schedule appointments because nobody shows up.”

So, we went back to Lynn and talked about not scheduling appointments. This turned into trying out the idea of (what Lynn called) on-demand appointments. That solution just took off. So that's one solution we came up with by accident, not planning. 51% of innovations come up by accident, not by planning. It was an Aha! moment that made a tremendous difference in treatment access. As Einstein said, "If we knew what we were doing, it wouldn't be research." It’s the stumbling along that brings about great ideas.”

What do you think has contributed to NIATx expansion?

“Many things contributed to NIATx expansion. A top factor was staying focused on our original four aims: reducing waiting time, reducing no-shows, increasing admissions, and increasing continuation. Don Holloway, who was part of the team that launched NIATx, told me to really drive that message whenever I got in front of a group to talk about what NIATx was and was not. Staying focused on just those four aims  (and nothing else) at a time made the change projects manageable for our providers versus feeling overwhelmed by the idea of having to overhaul their systems completely. Maintaining that single focus was important.

I also think that the simplicity of the NIATx change model is what makes it so powerful. We told providers that they only had to follow five principles—not 10 or 15—and that they only had to try a change for a very short time. If it worked, great. But if didn’t, then stop and try something else. The idea was to keep NIATx simple and fast-moving enough so people could easily adopt it.

Another factor in our success was the doors that Victor Capoccia and Fran Cotter from SAMHSA opened and their commitment to the project. SAMHSA-funded projects led from a focus on individual treatment agencies to the role of state agencies and the tremendous impact they can have on treatment delivery.

I would add research as another factor contributing to the NIATx trajectory, with work by Todd Molfenter, Jay Ford, and others helping drive widespread implementation and testing in new spaces. Plus, the NIATx Change Leader Academy (CLA) that we launched in 2006 has played a huge role in dissemination efforts and has trained hundreds nationwide.  Mat Roosa and Scott Gatzke continue to refine the CLA to respond to the field’s evolving needs, including work with Alfredo Cerrato on applying NIATx tools to foster cultural responsiveness. That’s really exciting. 

And then, the stories. How many times have I told the story of creating a persona of someone with a heroin addiction and then trying to get my persona admitted for treatment? How I was told to call back for seven weeks in a row to find out if a bed was available when my persona was ready for (and needed) treatment that day! While the science is there, it’s anemic compared to a great story. And, of course, the ATTC/NIATx Service Improvement Blog has been a great way for sharing these stories over the past decade.”

Are you using NIATx tools in your current research?

“The NIATx approach is embedded in the way I think about things and continue to integrate into everything I do. One project that’s been a great interest of mine for some time is the idea of automating addiction treatment, or in other words, finding ways to explore how technology, and that includes AI, can play a role in prevention, treatment, and recovery. The NIATx model of rapid cycle improvement is playing a fundamental role in that effort right now.”

What aspects of your current research are you most excited about?

“One of our current initiatives involves weekly Zoom meetups with around 60 older adults. We kick things off by having participants break into small groups to share something positive or challenging that’s happened in the previous week. We spend the initial 10 minutes in open conversation, then shift gears—assigning someone to lead a discussion on a weekly theme. It could be something as straightforward as dietary choices for older adults, a shared concern for everyone. Then, a member of our research team will give a brief but informative lecture on the topic, followed by a wrap-up 30-minute discussion where everyone pitches in with their thoughts. Towards the end, we summarize the key takeaways and wrap up with a movement exercise.

The impact has been astounding. I initially thought the idea of bringing people together on Zoom was good, but it turns out it's a great idea! I've never experienced such a profound response before. People are emotionally moved, and some have even teared up when they learn that the intervention is coming to an end. That leads us to ask what the next step is. What's the message here, and where is this taking us? It's been a powerful journey, and the participants' emotional response speaks volumes about this project's impact.”

Guest Post — Still Reaching: The Syndemics that Complicate and Characterize How Drugs and HIV Intersect in People’s Lives

 (Editor's note: This post originally appeared on the National Institute on Drug Abuse blog. It is reprinted here with permission from NIDA.)


Nearly 42 years ago, the Centers for Disease Control and Prevention (CDC) reported a rare pneumonia in five gay men, marking the recognized start of the HIV/AIDS epidemic. While we often hear about those men’s sexuality, we hear less often about their substance use. As the 1981 report notes, one of those five men injected drugs, and all five used drugs.

The history of HIV has long been entwined with substance use. In the United States today, more than 30,000 people acquire HIV every year while the drug overdose crisis cost the lives of nearly 107,000 people in 2021. Research shows people with HIV are more vulnerable to drug overdose than are those without HIV.

Because substance use plays such a significant role in HIV transmission and in health outcomes for people living with HIV, the National Institute on Drug Abuse (NIDA) is one of the largest funders of HIV research at the National Institutes of Health (NIH). We highlight the stories behind this essential research in the video series, “At the Intersection: Stories of Research, Compassion, and HIV Services for People Who Use Drugs.”

What is a syndemic?

Syndemics happen when two or more diseases interact to amplify each other—leading to an excess burden of disease and perpetuating health disparities. In a syndemic, environmental and social factors, like lack of quality healthcare, can make people more likely to be exposed to and experience worse outcomes from diseases. Having one health condition can also make people biologically or behaviorally more likely to acquire another illness.  However, science shows that when we address syndemic diseases together, outcomes for both can improve—especially when we integrate a variety of medical and social services with community support programs.

Approaching HIV, substance use, and other health issues through this lens can identify new opportunities to intervene that are invisible when we look at each issue alone.

Methamphetamine use, HIV, and mental health issues

A 2020 NIDA-supported study showed that as many as one in three new HIV transmissions among sexual and gender minorities who have sex with men were in people who regularly use methamphetamine. Many participants reported using methamphetamine to enhance sexual experiences, sometimes called “partying and playing.” Other NIDA-funded research shows that individuals who use methamphetamine are more likely to have sex without HIV prevention; to have mental health issues like depression, anxiety, or bipolar disorder; and are more likely to have detectable HIV viral loads and less likely to take HIV treatment and prevention medication. Fortunately, approaches that emphasize compassion and flexibility over judgement show promise in helping people who use meth achieve their health goals, take medication, and reduce their drug use or stay safer when they are using.

Substance use, HIV, and syringe sharing

Since 2014, there have been at least nine HIV outbreaks associated with the sharing and reusing of syringes in communities of people who inject drugs. CDC- and NIDA-funded researchers have identified factors associated with such outbreaks, including higher rates of hepatitis C and drug overdose, poverty, and lower levels of education. Fortunately, decades of research show that syringe services programs are safe, effective ways to reduce syringe sharing—and with it, the risk of acquiring HIV. Today, many syringe services programs also offer the overdose antidote naloxone and medications for opioid use disorder (MOUD), as well as HIV testing, prevention tools and treatment.

Substance use, HIV, and stigma, criminalization, and violence

People with HIV and substance use disorder (SUD) struggle to access quality, evidence-based healthcare. Racism, homophobia, transphobia, and HIV- and SUD-related stigma in healthcare are serious problems. Policies that punish drug use and criminalize HIV status can lead to time in jails and prisons, where access to HIV and SUD services may be limited. Immediately after incarceration, people are at greater risk of overdose and of leaving HIV care.

These factors—plus high rates of intimate-partner violence (especially among transgender and cisgender women living with HIV), childhood abuse, and other trauma—mean many people face intersectional factors leading to poor HIV and substance use outcomes. But NIDA-funded research shows promising ways forward, including integrated care that addresses the totality of people’s lives. For example, “one-stop” clinics—like the mobile health units in the NIDA-supported INTEGRA trial—test the impact of offering comprehensive services delivered by trained peer navigators who can connect with participants’ diverse experiences.

Bottom Line

Meeting people where they are to provide harm reduction and healthcare without stigma and treating the totality of people’s lives offers hope. And that hope is essential to ending the HIV epidemic.