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The federal Opioid State Targeted Response (Opioid STR) grants provided funding to each state to ramp up the range of responses to reverse the ongoing opioid crisis in the U.S. Washington State used these funds to develop and implement an integrated care model to expand access to medication treatment and reduce unmet need for people with opioid use disorders (OUD), regardless of how they enter the treatment system. This paper examines the design, early implementation and results of the Washington State Hub and Spoke Model. Methods: Descriptive data were gathered from key informants, document review, and aggregate data reported by hubs and spokes to Washington State's Opioid STR team. Results: The Washington State Hub and Spoke Model reflects a flexible approach that incorporates primary care and substance use treatment programs, as well as outreach, referral and social service organizations, and a nurse care manager. Hubs could be any type of program that had the required expertise and capacity to lead their network in medication treatment for OUD, including all three FDA-approved medications. Six hub-spoke networks were funded, with 8 unique agencies on average, and multiple sites. About 150 prescribers are in these networks (25 on average). In the first 18 months, nearly 5000 people were inducted onto OUD medication treatment: 73% on buprenorphine, 19% on methadone, and 9% on naltrexone. Conclusions: The Washington State Hub and Spoke Model built on prior approaches to improve the delivery system for OUD medication treatment and support services, by increasing integration of care, ensuring "no wrong door," engaging with community agencies, and supporting providers who are offering medication treatment. It used essential elements from existing integrated care OUD treatment models, but allowed for organic restructuring to meet the population needs within a community. To date, there have been challenges and successes, but with this approach, Washington State has provided medication treatment for OUD to nearly 5000 people. Sustainability efforts are underway. In the face of the ongoing opioid crisis, it remains essential to develop, implement and evaluate novel models, such as Washington's Hub and Spoke approach, to improve treatment access and increase capacity.

Marijuana use has been linked to a wide variety of negative consequences, especially for those who initiate use in early adolescence and become daily or regular users as a teenager. If these negative consequences are to be avoided, prevention efforts must focus upstream on childhood and adolescent developmental periods before marijuana use is initiated or has become frequent. Upstream prevention targets factors that predict initiation and escalation of marijuana use, which are often called risk and protective factors. This chapter provides a review of current knowledge about risk and protective factors, with an emphasis on psychosocial variables specific to marijuana, differentiating predictors of marijuana use from predictors of other legal and illegal drugs when possible. The chapter also provides suggestions for future research in light of the rapidly changing legal and community conditions related to access, availability, and norms of marijuana use.