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Abstract: This poster reports on an initiative to implement HIV rapid testing in substance abuse treatment programs in the state of South Carolina. A multi-agency collaboration between the Single State Authority, the state Health Department, the regional Addiction Technology Transfer Center (ATTC), and one substance abuse treatment program (Lexington-Richland Alcohol and Drug Abuse Council (LRADAC)), facilitated state-wide implementation. LRADAC, a community-based treatment program, was one of twelve sites that participated in the CTN trial on HIV rapid testing (protocol CTN-0032). Upon completion of the trial, LRADAC implemented a rapid HIV testing and counseling program as a clinical service. South Carolina’s previous efforts to implement on-site rapid HIV testing in 10 pilot agencies had less than optimal success due to the absence of a successful model on which agencies could base their implementation plan. With support from the collaborating agencies, staff developed and presented a 2 1/2 day HIV testing and counseling curriculum at the annual SC School of Alcohol and Drug Studies in 2010. Following the successful completion of the course, participants were fully certified to conduct testing and counseling in their local programs. Course participants had the opportunity to learn the counseling and testing procedures that LRADAC staff found successful in implementing their program. Although challenging, implementing HIV testing program in substance abuse treatment programs is feasible for agencies. The multi-agency collaboration in South Carolina supported the development of an HIV testing and counseling course that was team taught and showcased a successful model on which implementation could be based. Consequently, this effort increased the likelihood that additional substance abuse agencies within the state would move forward with implementation. Related protocols: CTN-0032

Abstract:

Clinical research is increasingly being conducted in community-based addiction treatment settings. Although the primary focus of such research is on the development of effective clinical interventions, less attention has been paid to the potential impact of these projects on counseling staff who are involved in their implementation. Such involvement may be perceived as stressful or rewarding, and these perceptions may be associated with counselors’ intention to remain in their jobs (“turnover intention”). Using data from 207 counselors involved in research projects conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN), this study examines the associations between counselors’ reactions to research experiences and turnover intention. Counselors’ turnover intentions were found to be associated with their perceptions about the research activities their organizations were involved in. Turnover intention was significantly greater whenever counselors perceived that their job demands had increased due to the research. However, turnover intention was significantly lower if counselors perceived that the research was resulting in improvements for their clients and organization.

These findings suggest that the impact of clinical trials on treatment organizations and staff members warrants continued study.

Abstract:

This paper reports on a cost-effectiveness study of protocol CTN-0007, designed to determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is worth the additional cost to treatment agencies. Six methadone maintenance community-based treatment programs (CTPs) in the CTN participated, with a study sample of 388 participants, 190 in the UC condition and 198 in the CM condition (which combined usual care with contingency management).

The authors found that prize-based contingency management provided better patient outcomes than usual care, but required additional costs. Compared to usual care, the incremental cost of using prize-based contingency management to lengthen the longest duration of abstinence (LDA) by one week was $141. The incremental cost to obtain an additional stimulant-negative urine sample was $70. Whether this extra expenditure is worthwhile depends upon the value placed on these outcomes. Using only the benefit of averted crime, an acceptability curve developed by the authors demonstrates a cost-effectiveness benefit of 90%. However, this estimate is quite conservative because averted crime is only one of the many potential benefits of a reduction in substance abuse. By comparing this study to a companion study, the authors also found that adding prize-based contingency management to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics. Further empirical analyses are needed to help policy makers decide whether CM is worth the extra expense; this paper helps to build an empirical basis for these important decisions.

Related protocols: CTN-0007-A-2

Abstract:

The importance of implementing evidence-based practices has taken over health care, whether in the mental health, medical, or substance use treatment realms. While well-intentioned and important, the implementation of evidence-based practices is only one aspect of quality care. In fact, there are many other elements of treatment that are at least as important as offering evidence-based practices, and this is particularly true in levels of care other than traditional outpatient. Other elements of care essential to quality treatment include: 1) Monitoring and ensuring a positive therapeutic alliance between clients and providers – Much research has documented the relationship between positive treatment outcome and a positive therapeutic alliance; 2) Monitoring and ensuring high customer satisfaction: Regardless of the specific treatment offered, it is essential to monitor and address customer satisfaction, as without this, clients will not obtain benefit from treatment; 3) Monitoring administrative discharges – In residential treatment programs, clients are often discharged for non-compliance with treatment. This needs close monitoring, as from experience, administrative discharges have more to do with staff than with clients; 4) Ensuring readily-available treatment access – When individuals are ready to enter treatment, treatment needs to be available. Treatment not being available or long waiting periods to enter treatment will result in lost opportunities; 5) Monitoring no-show rates and overall treatment retention – People have to come to treatment and be retained for treatment to be effective. Thus, a focus on this is necessary; 6) Ensuring clients – multiple treatment needs are addressed – Either in-house or through linkages, clients – other problems need to be addressed; and 7) Ongoing quality improvement – To ensure quality treatment, a culture of continuous quality improvement must be developed.

This presentation will highlight other important aspects of care that must not be forgotten while programs are focused on implementing evidence-based practices.

Abstract:

In the context of a contingency management (CM) implementation/effectiveness hybrid trial, the post-training implementation domains of direct-care clinicians affiliated with one of the community treatment programs in the Pacific Northwest Node of the NIDA Clinical Trials Network (N=19) were examined in relation to a targeted clinical outcome of subsequently CM-exposed clients. Clinicians’ CM skillfulness, a behavioral measure of their capability to skillfully deliver the intended CM intervention, was found to be a robust and specific predictor of their subsequent client outcomes. Analyses also revealed CM skillfulness to: (1) fully mediate an association between a general therapeutic effectiveness and client outcome; (2) partially mediate an association of in-training exposure to CM and client outcomes; and (3) be composed of six component clinical practice behaviors that each contributed meaningfully to this behavior fidelity index.

Conclusions: Study findings offer preliminary evidence of the predictive validity of post-training CM skillfulness for subsequent client outcomes. This suggests an apparent value in providing skills-focused training in CM, and perhaps other empirically-supported behavior therapies. Skills-focused training does not necessarily preclude trainer use of didactic and discussion elements in CM training curricula, presumably for purposes of enhancing clinician knowledge of core operant conditions principles and practices, as well as to dispel myths and misconceptions that deter adoption readiness. However, current findings provide preliminary evidence to suggest such passive learning strategies are insufficient if the goal of behavior therapy training is to prepare a workforce to effectively implement a new approach.

Abstract:

It is often difficult for evidence-based practices (EBPs) to find their way into addiction treatment programs. One goal of the National Institute on Drug Abuse’s Clinical Trials Network (CTN) is to disseminate these EBPs into community treatment programs. The Southwest Node of the CTN hosted a series of 13 local workshops in EBPs led by experts in the topic areas. Participants (N=327) were asked to complete an online evaluation of the training with a follow-up rate of 75.8%. Respondents reported that the trainings had been applied to their workplace. Qualitative analysis revealed themes of gratitude and a need for additional training opportunities. Participant enthusiasm for training was indicated by the willingness to travel up to a thousand miles and independently pay for travel expenses.

Conclusions: Results suggest that following a workshop training in EBPs, participants reported long-term (14 month) high satisfaction with the training and believed the trainings had been incorporated into their daily practice. Frontline providers are aware of EBPs and eager for further trainings. However, future dissemination studies in front-line settings should involve formal assessments of training needs, objective measures of skill acquisition, and inclusion of training enrichments to supplement the workshop format.

Abstract:

Despite research demonstrating its effectiveness, use of contingency management (CM) in substance use disorder treatment has been limited. Given the vital role that counselors play as arbiters in the use of therapies, examination of their use of and attitudes toward CM could provide insight into how to better promote further use of the intervention. This paper examines 731 counselors’ attitudes toward the effectiveness and acceptability of CM in treatment, as well as their specific attitudes toward both unspecified and tangible incentives for treatment attendance and abstinence. Compared to cognitive behavioral therapy, motivational interviewing, and community reinforcement approach, counselors rated CM as the least effective and least acceptable psychosocial intervention. Exposure through use of CM in a counselor’s employing organization was positively associated with perceptions of acceptability, agreement that incentives have a positive effect on the client-counselor relationship, and endorsement of tangible incentives for abstinence. Endorsement of tangible incentives for treatment attendance was significantly greater among counselors with more years in the treatment field, and counselors who held at least a Master’s degree. Counselors’ adaptability or openness to innovations was also positively associated with attitudes toward CM. Further, female counselors and counselors with a greater 12-step philosophy were less likely to endorse the use of incentives.

A highlight of this study is that it offers the first specific assessment of the impact of “Promoting Awareness of Motivational Incentives” (PAMI), a web-based tool based on findings of CM protocols tested within the Clinical Trials Network (CTN), on counselors employed outside the CTN. We found that 10% of counselors had accessed PAMI, and those who had accessed PAMI were more likely to report a higher degree of perceived effectiveness of CM than those who had not.

Conclusions: The effectiveness of SUD treatment will be enhanced by the breadth of the menu of treatment offerings that are offered by providers, assuming appropriate fidelity to the design of these interventions. Given the barriers to CM adoption, identifying predictors of positive CM attitudes among counselors can help diffuse CM into routine clinical practice. Exposure is important in ensuring proper delivery of such treatment, and training could help decrease the reluctance of paying individuals for treatment attendance or abstinence. This study lays in the groundwork for vital research on the impact of multiple web-based educational strategies. Future research should focus on differential effectiveness of different educational strategies, consider the attitudes of patients themselves, and explore the orientations toward practices such as CM among third-party payers. Given the barriers to CM adoption, identifying predictors of positive attitudes among counselors can help diffuse CM into routine clinical practice.

Related protocols: CTN-0006, CTN-0007

Abstract:

Recent federal legislation and a renewed focus on integrative care models underscore the need for economical, effective, and science-based behavioral health care treatment. As such, maximizing the impact and reach of treatment research is of great concern. Behavioral health issues, including the frequent co-occurrence of substance use disorders (SUD) and post-traumatic stress disorder (PTSD), are often complex, with a myriad of factors contributing to the success of interventions. Although treatment guides for comorbid SUD/PTSD exist, most patients continue to suffer symptoms following the prescribed treatment course. Further, the study of efficacious treatments has been hampered by methodological challenges (e.g., overreliance on “superiority” designs (i.e., designs structured to test whether or not one treatment statistically surpasses another in terms of effect sizes) and short term interventions). Secondary analyses of randomized controlled clinical trials offer potential benefits to enhance understanding of findings and increase the personalization of treatment.

This paper offers a description of the limits of randomized controlled trials as related to SUD/PTSD populations, highlights the benefits and potential pitfalls of secondary analytic techniques, and uses as a case example one of the largest effectiveness trials of behavioral treatment for co-occurring SUD/PTSD conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN). The paper concludes with implications of this secondary analytic approach to improve addiction researchers’ ability to identify best practices for community-based treatment of these disorders.

Conclusions: Innovative methods are needed to maximize the benefits of clinical studies and better support SUD/PTSD treatment options for both specialty and non-specialty healthcare settings. Given the continuing gap between research and practice, appropriately executed secondary analytic studies are an important step in addressing questions that have real-world value to community clinicians. Moving forward, planning for and description of secondary analyses in randomized trials should be given equal consideration and care to the primary outcome analysis.

Abstract:

Problem alcohol use is associated with adverse health and economic outcomes, especially among people in opioid agonist treatment. Screening, brief intervention, and referral to treatment (SBIRT) are effective in reducing alcohol use; however, issues involved in SBIRT implementation among opioid agonist patients are unknown. To assess identification and treatment of alcohol use disorders, this study, partially funded by the Western States Node of the National Drug Abuse Treatment Clinical Trials Network, reviewed clinical records of opioid agonist patients screened for an alcohol use disorder in a primary care clinic (n=208) and in an opioid treatment program (n=204) over a two-year period.

In the primary care clinic, 193 (93%) buprenorphine patients completed an annual alcohol screening and six (3%) had elevated AUDIT scores. In the opioid treatment program, an alcohol abuse or dependence diagnosis was recorded for 54 (27%) methadone patients. Practitioner focus groups were completed in the primary care (n=4 physicians) and the opioid treatment program (n=11 counselors) to assess experience with and attitudes towards screening opioid agonist patients for alcohol use disorders. Focus groups suggested that organizational, structural, provider, patient, and community variables hindered or fostered alcohol screening.

Conclusions: Training health professionals in alcohol screening and intervention is a feasible and acceptable way of improving care for opioid agonist patients. Effective implementation requires systematic changes at multiple levels targeting obstacles specific to patient population or setting. Strategies that support implementation of SBIRT among opioid agonist patients, and similar vulnerable populations, include structural changes, interactive workshops, clinical guidelines, improved medical records, and clinic work-flows. These lessons learned from implementation of alcohol screening within a primary care clinic can be adapted for specialty care and should be promoted and tailored to the specific population or setting under study.

Abstract:

The high prevalence of trauma and post-traumatic stress disorder (PTSD) in individuals with substance use disorders (SUDs) presents a number of treatment challenges for community treatment providers and programs in the U.S. Although several evidence-based, integrated therapies for the treatment of comorbid PTSD/SUD have been developed, rates of utilization of such practices remain low in community treatment programs. The goal of this article was to review the extant literature on common barriers that prevent adoption and implementation of integrated treatments for PTSD/SUD among substance abuse community treatment programs. Organizational, provider-level and patient-level factors that drive practice decisions were discussed, including organizational philosophy of care policies, funding and resources, as well as provider and patient knowledge and attitudes related to implementation of new integrated treatments for comorbid PTSD as SUD.

Conclusions: Despite increasing awareness of the need to address comorbid PTSD and SUD, organization-, provider- and patient-level factors present challenges to the implementation of integrated therapies in front line community substance abuse treatment programs. Understanding and addressing these challenges may facilitate use of evidence-based integrated treatments for comorbid PTSD and SUD.

Abstract:

Rates of adoption of evidenced-based practices to treat opioid dependence, including the use of medications, are low and severely limit secondary prevention efforts to curtail the prescription drug epidemic. The goal of this article was to describe how involvement in a research clinical trials network, the National Drug Abuse Treatment Clinical Trials Network (CTN), facilitated the adoption of medications to treat opioid dependence at two community-based treatment programs (CTPs) affiliated with the Ohio Valley Node (OVN) of the network. Both programs are large, not-for-profit facilities that treat patients with either public or private insurance. One program, Maryhaven, had limited experience using FDA-approved medications to treat opioid dependence before joining the CTN; the other, Midtown, had a methadone clinic but no experience with buprenorphine or naltrexone. This article discusses the adoption of medications to treat opioid dependence in these two programs by highlighting critical turning points, lessons learned, and challenges encountered.

Conclusions: The NIDA CTN is a research network that facilitates the adoption of innovative science-based treatments for SUDs. One of the intrinsic values of participating in a research network is that the infrastructure allows opportunities for collaborative relationships to develop, building trust over time, and ultimately providing a professional network that can provide technical assistance that may be the final barrier to adoption or serve as a tipping point for adoption. Participation in a clinical trials network may facilitate adoption by providing the infrastructure for trialability and observability, but the most critical function may be the knowledge translation that occurs through the individual-level professional relationships that develop.

Abstract:

This presentation provides an overview of the organization, mission, and history of NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) in New England, including clinical research trials completed by New England programs participating in the CTN. The CTN was developed partially in response to a 1998 Institute of Medicine Report that spoke of the “serious gaps of communication” between the research community and community-based drug treatment programs. There is also a gap between social work research and practice in the addictions, with one national study of MSW degree programs finding that only 14.3% of accredited schools offered specializations in addiction. The CTN is a partnership between academic research centers and community drug abuse treatment programs, with the aim of developing and implementing multi-site clinical research studies and supporting the dissemination and adoption of any evidence-based interventions that result.

The CTN in New England began with two nodes in 2002 — the Northern New England Node (with a Regional Research Training Center (RRTC) at McLean Hospital/Harvard) and the New England Node (RRTC at Yale). In 2010 (through the present), those two nodes were combined to form the New England Consortium Node (with McLean and Yale serving as co-RRTCs). The New England node(s) have participated in 9 protocols (as well as the 2 additional baseline studies all CTN organizations participated in), between 2002-2013. Aims and outcomes from those studies are presented, followed by a brief introduction to some of the new studies currently being launched in the network.

CTN studies can also be used as a model to test interventions relevant to social work, such as sexual risk reduction skills training. Social workers are involved in the CTN, serving as study principal investigators, executive directors in treatment programs, program managers, counselors, and research assistants. The CTN is a valuable mechanism for training social workers in the delivery of empirically-supported treatments and counseling styles, and can also serve as a training platform for future careers in the field. Social workers can — and do! — play a vital role in helping to bridge the gap between research and treatment in the substance abuse field.

Abstract:

This ancillary investigation of data from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031 (“Stimulant Abuser Groups to Engage in 12-Step (STAGE 12)”) investigated the correspondence among four groups of raters on adherence to STAGE-12, a manualized 12-step facilitation (TSF) group and individual treatment targeting stimulant abuse. The four rater groups included the study therapists, supervisors, study-related (“TSF expert”) raters, and non-project-related (“external”) raters. Results indicated that external raters rated most critically Mean Adherence — the mean of all the adherence items — and global performance. External raters also demonstrated the highest degree of reliability with the designated expert. Therapists rated their own adherence lower, on average, than did supervisors and TSF expert raters, but therapist ratings also had the poorest reliability.

Conclusions: Findings highlight the challenges in developing practical, but effective methods of fidelity monitoring for evidence-based practice in clinical settings. While funding and licensing agencies increasingly call for use of evidence-based treatments, community-based organizations implementing them will seek the simplest, most reliable and cost-effective ways of monitoring their delivery. These results suggest that there may be a role for on-site therapists or supervisors rating adherence, and that raters unaffiliated with the treatment being tested may provide the most objective ratings. Future research should examine the impact of training therapists on self-rating to determine whether this group and achieve acceptable reliability and objectivity in ratings.

Related protocols: CTN-0031

Abstract:

The Affordable Care Act calls for integration of substance abuse treatment into medical care via medical homes and continuing specialty care. For this integration to occur in the substance abuse treatment field, substantial sharing and dissemination of information by treatment providers is required. This study explored the determinants of organizational activities directed at disseminating evidence-based practices (EBPs) undertaken by 193 community treatment programs who are members of the National Institute on Drug Abuse’s National Drug Abuse Treatment Clinical Trials Network (CTN). Using factor analysis, the research identified two generic categories reflecting different motivations for dissemination activities and explored both treatment center leadership and organizational characteristics as determinants of these different types of dissemination activities. Organizational characteristics predicting treatment center dissemination activities included size, previous involvement in research protocols, linkages with other providers, and having non-profit status. The treatment center leader’s membership in professional organizations was also a significant determinant. Organization variables account for a larger portion of the variance in treatment center dissemination activities.

Conclusions: The results suggest that the willingness of treatment providers to help disseminate EBPs within the industry may be heavily influenced through shared network connections with other treatment organizations. Policy leaders’ efforts to increase EBP implementation and care integration targeted by the ACA may want to pay particular attention to the effects of network involvement found in this study.

Abstract:

This presentation describes the CTN, provides an overview of its work, and highlights the applicability of its findings to social work research and practice. It focuses particularly on CTN studies conducted in the New England Node, and identifies linkages between clinical research, empirically-supported treatments, and social work practice in addictions.