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Abstract: Background: Opioid use disorder (OUD) remains a significant public health issue. Yet, few primary care clinicians (PCCs) screen for, diagnose, or treat OUD. Clinical decision support tools (CDS) integrated into the electronic health record improve process and outcome measures across a variety of conditions. We evaluated PCC perspectives on an OUD CDS tool (Opioid Wizard) deployed through a clinic-randomized trial. Methods: This is a secondary analysis of CTN-0095, a trial evaluating the effectiveness of Opioid Wizard on OUD process and outcome measures. In short, 92 primary care clinics across three health systems were randomized to Opioid Wizard or usual care. PCCs completed online surveys pre- and 9-month post-Opioid Wizard’s go-live date. Survey items measured PCC self-reports on their confidence and ability to manage OUD, and for PCCs in Opioid Wizard clinics, perceptions about the tool. Generalized linear mixed models with Poisson distribution estimated change in survey response from baseline to follow-up within each treatment group (risk ratios) and in intervention relative to control clinics (ratio of risk ratios). Results: 361 PCCs (n = 180 Opioid Wizard, n = 181 usual care, 63% female) answered at least one survey. Confidence in screening (RR 1.32, 95% CI 1.07, 1.62), diagnosing (RR 1.24, 95% CI 1.02, 1.50), and referring (RR 1.17, 95% CI 1.02, 1.34) patients for OUD care significantly increased in Opioid Wizard clinics only. Confidence in treating OUD with buprenorphine did not increase in either setting. Of 55 PCCs who used Opioid Wizard at least once, 80% agreed Opioid Wizard made tasks easier and 70% agreed using Opioid Wizard was time “well spent,” but only 44% were likely to recommend it to colleagues. Conclusion: Opioid Wizard increased PCC confidence across a variety of OUD care measures yet enthusiasm for and use of the tool was limited. Efforts to increase Opioid Wizard use may improve OUD care measures. Related protocols: CTN-0095

Abstract:

Starting in 2016, physician assistants (PAs) and Advanced Practice Registered Nurses could prescribe buprenorphine with an approved waiver, which improves health care through expansion of access to care, reduction of health care costs, and provision of high-quality care. This study, based on CTN-0089, addresses barriers to student NP’s and PA’s ability to prescribe buprenorphine by examining knowledge and attitudes toward prescribing medications for opioid use disorder (MOUD), subjective norms and perceived behavioral control surrounding prescribing MOUD, and the intention to prescribe MOUD among NPs and PAs. Participants were 120 students enrolled in the NP or PA program at 3 large universities in the southeastern United States. Before and after engagement in the 8-hour Waiver Training, participants completed a survey to obtain measures of knowledge, attitudes toward prescribing MOUD, subjective norms, perceived behavioral control, and intention to prescribe MOUD.

Results demonstrated increased knowledge regarding MOUD and prescribing practices from pre- to post-training. Students reported being significantly more likely to prescribe buprenorphine, methadone, and naltrexone after completing the waiver training, as well as stronger attitudes that MOUD is beneficial, useful, good, effective, and relevant. Student subjective norms did not significantly change from pre- to post-training, although perceived control significantly increased. Incorporation of training and treatment of patients with MOUD is critical for continued increases in the number of waivered providers.

Related protocols: CTN-0089

Abstract:

Southern U.S. communities experience high HIV incidence and substance use prevalence, yet low PrEP uptake. In CTN-0082, providers (N=191) completed a survey about willingness to refer/link clients with HIV risk to PrEP. Through in-depth interviews, 12 directors (5 sexually transmitted infection [STI] clinics; 5 syringe services programs [SSPs]; 2 substance use treatment programs [SUTPs]) described multi-level factors that contextualized provider willingness. Providers were more willing to refer/link clients with unspecified HIV risk and men who have sex with men to PrEP vs. other populations. SUTP (vs. SSP) providers were less willing to refer/link clients with unspecified risk and men who use opioids. Older (vs. younger) providers were less willing, and more (vs. less) experienced providers more willing to refer/link to PrEP. Directors described facilitators (e.g., comprehensive health center partnerships) and barriers (e.g., provider stigma toward people who use drugs) to PrEP implementation. Findings highlight the importance of considering multi-level factors in PrEP implementation.

Related protocols: CTN-0082

Abstract:

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however, addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model, which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting (at Willamette Family Treatment Services, part of the CTN Oregon/Hawaii Node). Other treatment programs may use the experience and lessons learned from this CTN platform study about the ATTOC organization change model to better address tobacco use in the context of drug abuse treatment.

Abstract:

The health services field is increasingly concerned about burnout and turnover among service providers. Substance abuse professionals are particularly susceptible to burnout since factors such as large caseloads, limited resources, low pay, and bureaucratic work environments contribute to burnout. In addition, substance abuse professionals work with a challenging client population of addicts and referrals from the criminal justice system which can leave them feeling frustrated, depressed, and helpless in assisting clients. Examining work environment factors that are amenable to change may make a difference in curbing burnout (and ultimately deterring turnover) among substance abuse counselors. Clinical supervision is one such factor, as it is the primary mechanism for on-the-job training and counselor development. Further, negative experiences in clinical supervision can contribute to burnout and ultimately turnover. As such, the authors propose that positive experiences with one’s clinical supervisor may reduce counselor burnout whereas negative experiences may actually exacerbate burnout. And consistent with previous research, burnout should predict counselor turnover intentions.

This poster describes the outcomes of a CTN platform study that surveyed 462 counselors employed at fifteen CTPs (community treatment programs) in the Clinical Trials Network. Two dimensions of burnout were examined: depersonalization and emotional exhaustion. The variables of role overload, job satisfaction, and pay satisfaction were used as control variables in all of the multiple regression analyses. The results indicate that both positive and negative clinical supervisory experiences are associated with turnover intentions. Likewise, counselor burnout was associated with turnover intentions. Further, both depersonalization and emotional exhaustion were partial mediators of the relationship between positive and negative clinical supervisory experiences and turnover intentions. This study indicates that high quality clinical supervision may be important in reducing burnout and subsequent counselor intentions to turnover. The practical suggestions include in-house and education-based training on effective clinical supervision and performance management systems that hold clinical supervisors accountable for their behavior toward counselors.

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:

Background: Individuals with opioid use disorder have high rates of hospital admissions, which represent a critical opportunity to engage patients and initiate medications for opioid use disorder (MOUD). However, few patients receive MOUD and, even if MOUD is initiated in the hospital, patients may encounter barriers to continuing MOUD in the community.

Objective: Describe hospital providers’ experiences and perspectives to inform initiatives and policies that support hospital-based MOUD initiation and continuation in community treatment programs.

Design: As part of a broader implementation study focused on inpatient MOUD (NCT#04921787), we conducted semi-structured interviews with hospital providers.

Participants: Fifty-seven hospital providers from 12 community hospitals.

Approach: Thematic analysis examined an emergent topic on challenges transitioning patients to outpatient MOUD treatment and related impacts on MOUD initiation by inpatient providers.

Key results: Participants described structural barriers to transitioning hospitalized patients to continuing outpatient MOUD including (a) limited outpatient buprenorphine prescriber availability, (b) the siloed nature of addiction treatment, and (c) long wait times. As a result of observing these structural barriers, participants experienced a sense of futility that deterred them from initiating MOUD. Participants proposed strategies that could better support these patient transitions, including developing partnerships between hospitals and outpatient addiction treatment and supporting in-reach services from community providers.

Conclusions: We identified concerns about inadequate and inaccessible community-based care and transition pathways that discouraged hospital providers from prescribing MOUD. As hospital-based opioid treatment models continue to expand, programmatic and policy strategies to support inpatient transitions to outpatient addiction treatment are needed.

Related protocols: CTN-0098

Abstract:

This is the primary outcomes paper for CTN-0105.

Background: Pharmacists play a key role in combating the opioid-related overdose epidemic in the United States (US), but little is known about their experience and willingness to deliver preventive services for opioid use disorder (OUD).

Aims: This study seeks to identify correlates of pharmacists’ concerns about drug use problems (prescription drug misuse/use disorder and illicit drug use/use disorder) as well as their practice experience delivering preventive services for OUD (e.g., asked about opioid use, provided advice, made a referral) and willingness to provide services to patients with drug use problems.

Design: An online survey of licensed US pharmacists was conducted. Participants were recruited from Community Pharmacy Enhanced Services Networks (CPESN) and state pharmacist associations (N=1146).

Findings: Overall, 75% of surveyed pharmacists indicated having concerns about opioid use problems, and 62% had concerns about non-opioid drug use problems at their pharmacies. Pharmacists who were White, practiced at a rural location, worked at a chain pharmacy, had not received opioid-related training in the past year, or practiced screening patients for opioid use had elevated odds of perceiving concerns about opioid use problems in their practice settings. Pharmacists who were White, practiced at a rural location, or had not received opioid-related training in the past year had elevated odds of perceiving concerns about non-opioid (illicit) drug use problems. Being male, being White, or having received opioid-related training were associated with increased odds of screening patients for opioid use problems. Being White, having practiced at a rural location (vs. an urban location), being a pharmacy owner/manager, or having received opioid-related training were associated with increased odds of delivering opioid-related advice/intervention. Being male or having received opioid-related training were associated with increased odds of making a referral to OUD treatment. Finally, being male, being White, having practiced pharmacy services for under 6 years, having received opioid-related training for 2 h in the past year, or having performed OUD-related preventive services (asked about opioid use, provided advice, or made a referral) were associated with increased levels of commitment/readiness for providing care to patients with drug use problems.

Conclusions: The overall findings highlight pharmacists’ involvement with OUD preventive services. It is critical to promote opioid-related preventive service training for pharmacists and provide incentives/tools to help initiate a structured practice of delivering such preventive services.

Related protocols: CTN-0105

Abstract:

Pharmacists are on the frontline caring for patients at risk of an opioid overdose and for patients with an opioid use disorder (OUD). Dispensing naloxone and medications for OUD and counseling patients about these medications are way pharmacists can provide care. Key to pharmacists’ involvement is their willingness to take on these practice responsibilities.

As part of NIDA Clinical Trials Network protocol CTN-0075, Physician-Pharmacist Collaboration in the Management of Patients with Opioid Use Disorder, this scoping review aimed to identify, evaluate, and summarize published literature describing pharmacists’ attitudes toward naloxone and medications for OUD, i.e., methadone, buprenorphine, and naltrexone. All searches were performed on December 7, 2015, in 5 databases: Embase.com, PubMed.gov, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost, Cochrane Central Register of Controlled Trials via Wiley, and Clarivate Web of Science. Articles included original research conducted in the United States, described attitude-related language toward naloxone and medications for OUD, and pharmacists.

A total of 1323 articles were retrieved, 7 were included. Five studies reported on pharmacists’ attitudes toward naloxone dispensing; 1 study reported on attitudes toward naloxone, buprenorphine, and buprenorphine/naloxone; and 1 reported on attitudes toward buprenorphine/naloxone. Respondents were diverse, including pharmacists from different practice specialties.

Studies found that pharmacists agreed with a naloxone standing order, believed that naloxone should be dispensed to individuals at risk of an opioid overdose, and were supportive of dispensing buprenorphine. A minority of pharmacists expressed negative attitudes. Barriers cited to implementation included education and training, workflow, and management support.

Conclusions: Pharmacists were positive in their attitudes toward increased practice responsibilities for patients at risk of an opioid overdose or with an OUD. Pharmacists must receive education and training to be current in their understanding of OUD medications, and they must be supported in order to provide effective care to this patient population.

Related protocols: CTN-0075

Abstract:

While patient navigation has been shown to be an effective approach for linking persons to HIV care, and contingency management is effective at improving substance use-related outcomes, Project HOPE combined these two interventions in a novel way to engage HIV-positive patients with HIV and substance use treatment.

The aims of this paper are to examine patient navigator views regarding how contingency management interacted with and affected their navigation process. Individual, semi-structured interviews lasting approximately 60 minutes were administered to 22 patient navigators from the original 10 Project HOPE study sites. The interviews address the patient navigator’s professional background, descriptions of the participant population, substance use disorder vs. HIV treatment entry and engagement issues, and the use of contingency management within the navigation service delivery protocol.

Patient navigators believed that financial incentives helped motivate participant attendance at navigation sessions, particularly early in study involvement, which helped them to establish rapport and develop relationships with participants. Patient navigators often noted that financial incentives positively influenced targeted HIV health-related behaviors, such as attending medical appointments, which provided a rapid pay-off with an escalating sum. Contingency management was more complex when used by the patient navigators for substance use-related behaviors, particularly when incentives revolved around negative urine screening. Patient navigators noted that not all participants responded the same way to the contingency management and that the incentives were particularly helpful when participants were financially strained with limited resources or when internal motivation was lacking.

Conclusions: Overall, patient navigators found the inclusion of contingency management to be helpful and effective at influencing participant behaviors, particularly concerning navigation session attendance and HIV healthcare-related participation. However, issues and concerns surrounding the inclusion of contingency management for drug-related behaviors as delivered in Project HOPE were noted.

Related protocols: CTN-0049

Abstract:

This study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes. Clients in 25 NIDA Clinical Trials Network-affiliated treatment programs were surveyed in 2015 (N=1,176) and 2016 (N=1,055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016.

Results found one difference across such years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=.031), mean CPD decreased (10.62 v. 8.24, p<.001) and mean tobacco services received by clients increased (2.08 v. 3.05, p<.001).

Conclusions: Findings indicate first, little change over time in smoking prevalence or other smoking-related measures in this population, and second, support the use of tobacco-free grounds policies as a strategy to address smoking in these settings. The authors recommend that the Center for Substance Abuse Treatment require tobacco-free grounds policies as a condition for block grant and capacity expansion funding to addiction treatment programs, that state agencies concerned with regulation and licensing of addiction treatment programs require adoption of tobacco-free grounds and that, even in the absence of a future mandate, addiction treatment programs implement tobacco-free grounds as a way to reduce health risks for both program staff and clients.

Abstract:

Smoking is endemic in drug abuse treatment populations, and smoking prevalence in this population appears unresponsive to existing tobacco control strategies. Clinical and policy guidelines encourage programs to address smoking among clients, and research has identified key barriers to doing so. This report explores the practice of staff and clients smoking together in drug treatment programs, and how this practice is associated with other tobacco-related measures. Clients (N=1113) were surveyed and program directors were interviewed in a national sample of 24 drug abuse treatment programs affiliated with the NIDA Clinical Trials Network. Clients were asked whether they observed staff and clients smoking together in their program and, using program as the unit of analysis, this measure was tested for its association with client-level and program-level tobacco-related outcomes. Higher rates of staff and client smoking together were associated with higher staff smoking prevalence (p=0.006), lower rates of client thoughts about quitting in the next 30 days (p=0.027), more negative client attitudes toward quitting smoking (p=0.004), and with clients receiving fewer tobacco-related services (p=0.024).

Conclusions: These findings illuminate an actionable, low-cost policy intervention to address smoking in drug abuse treatment: prohibiting the practice of staff smoking together with clients. There may be challenges to face in changing a practice that is culturally accepted in some program (for example, some believe that smoking together builds rapport/trust). Despite these challenges, however, there is no reason to continue the practice of staff and clients smoking together. In the interest of the health of clients whom they serve, counselors, program directors, state regulatory agencies, and federal funding agencies should act to end this practice.

Abstract:

Decreasing smoking during pregnancy is a priority in both research and clinical practice. In contrast, despite the high prevalence of smoking in pregnant substance users (upward of 90%), smoking-cessation treatment has received relatively little attention in substance use disorder treatment. Several barriers to integrating smoking cessation treatment interventions into SUD treatment have been delineated, including the belief that smoking is unrelated to substance use and that substance using smokers don’t want to quit smoking. Research has demonstrated these beliefs may not be accurate, but less is known about all these factors in pregnant women.

The goal of this secondary analysis was to test hypotheses that in pregnant substance users: (1) cigarette smoking would be associated with greater alcohol and drug use; (2) approximately 50% of smokers would be interested in quitting smoking; and (3) greater self-efficacy and lower perceived difficulty of smoking would be associated with interest in quitting smoking.

Data from a randomized, multisite trial (CTN-0013) with 200 pregnant substance users, 145 (72.5%) of whom smoked at baseline, was analyzed. As predicted: (1) smokers had significantly greater substance use; (2) approximately half of smokers wanted to quit; and (3) smokers with a quit goal had significantly greater self-efficacy and lower perceived difficulty of quitting.

Conclusions: Smoking may be associated with more severe substance use in pregnant substance-using patients, half of whom may be interested in smoking-cessation interventions. These findings highlight the importance of addressing smoking in pregnant substance users. While some work is being done to identify effective smoking-cessation interventions for this population, this remains a significant clinical and research need.

Related protocols: CTN-0013

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:

In the US, there are approximately two million substance users in community treatment programs who are at risk for HIV. Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV acquisition among individuals at risk for HIV, if they are adherent to its use, and it has recently been approved by the FDA. This study aimed to examine substance abuse treatment providers’ views on engaging clients in PrEP care and research trials. Thirty-six medical and counseling service providers in six New York City outpatient substance abuse treatment programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN) participated in semi-structured qualitative interviews. Thematic content analysis was conducted by three coders, independently.

Providers’ perspectives toward PrEP were characterized by six salient themes: 1) Limited PrEP awareness. 2) Ambivalence about PrEP. 3) Perception of multiple challenges to delivery. 4) Uncertainty about clients’ ability to be adherent to medication. 5) Concerns about medication safety/side effects. 6) Perception of multiple barriers to conducting clinical trials.

Conclusions: This is the first study to explore substance abuse treatment providers’ views on PrEP. Despite anticipated challenges, providers supported the introduction of PrEP in outpatient substance abuse treatment. Comprehensive training for providers is needed and should include PrEP eligibility criteria, strategies to support adherence, and medication monitoring guidelines. Linkages between substance abuse treatment and primary care and/or enhancement of capacity within clinics to offer PrEP may help facilitate PrEP delivery. Given access to training, supervision, and linkages to appropriate referral sources, substance abuse treatment providers are likely to engage at-risk clients in accessing PrEP.