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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:

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:

Teleconferencing Supervision is a method for training community-based substance abuse clinicians in Motivational Interviewing (MI). In this CTN platform study, 13 clinicians recruited from 3 community treatment programs in the Long Island Node of the Clinical Trials Network attended a 2-day workshop and then received live supervision via telephone during 5 counseling sessions conducted at their community treatment facilities. Clinicians were assessed for skill level at post-workshop, at post-training, and 3 months later; learning was assessed using the MI Treatment Integrity instrument. All summary scores and therapist behavior frequency counts improved by post-training or by the 3 month follow-up, although some gains were not statistically significant.

This study suggests that Teleconferencing Supervision may help facilitate the proficient use of MI community clinicians following workshop instruction. By enabling both clinicians and supervisors to participate from their respective home bases, it is hoped that the TCS model will be able to project training to a broader range of community treatment programs.

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:

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.

Abstract:

Large-scale dissemination efforts seek to expand opportunities for the addiction treatment community to receive training in empirically supported treatments (ESTs). Prospective consumers of such training are valuable sources of input about content of interest, preferences for how training events are structured, and obstacles that deter receipt of training. In this mixed-method study, data were collected in 64 semistructured individual interviews with personnel during site visits to 16 community opioid treatment programs (OTPs). At each OTP, interviews were completed with the executive director, a clinical supervisor, and 2 direct-service clinicians.

Topical interests were analyzed qualitatively in a cultural domain analysis. Likert ratings of training event preferences were analyzed via generalized linear mixed models (GLMMs), and unstructured interviewee comments were analyzed via narrative analysis. Obstacles to training receipt were analyzed qualitatively with both content coding and narrative analysis. Based on topics of reported interest, cultural domain analysis suggests as ESTs of note: Multidimentional Family Therapy, Motivational Enhancement Therapy, Relapse Prevention Therapy, “Seeking Safety,” and broad addiction-focused pharmacotherapy. Regarding training event preferences, GLMMs and narrative analysis revealed clear preferences for time-distributed trainings and use of participatory activities (e.g., trainer demonstrations, role plays, small group exercises). Content coding identified cost as the primary obstacle to receipt of EST trainings, followed by lack of time, logistical challenges, and disinterest, and narrative analysis elaborated on contextual issues underlying these obstacles.

Conclusions: As primary consumers of EST technologies, the treatment community has valuable input to offer. Dissemination efforts may be enhanced by greater consideration of their preferences for training content and event structure, as well as practical obstacles that challenge their receipt of training.

Abstract:

There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner-scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (n=345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (n=198). Models included 922 counselors in 172 CTN programs and 1,203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs.

Conclusions: This study suggests that research network affiliation positively impacts counselors’ acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment.

Abstract:

This study examined the relationships between treatment fidelity and treatment outcomes in a community-based trial of 12-Step Facilitation (TSF) intervention. In a prior multi-site randomized clinical trial, National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031, 234 participants in 10 outpatient drug treatment clinics were assigned to receive the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention. This secondary analysis reviewed and coded all STAGE-12 sessions for fidelity to the protocol, using the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF-ACES). Linear mixed-effects models tested the relationship between three fidelity measures (adherence, competence, empathy) and six treatment outcomes (number of days of drug use and five Addiction Severity Index (ASI) composite scores) measured at 3 months post-baseline. Adherence, competence, and empathy were robustly associated with improved employment status at follow up. Empathy was inversely associated with drug use, as was competence in a non-significant trend (p=.06). Testing individual ASI drug composite score items suggested that greater competence was associated with fewer days of drug use and, at the same time, with an increased sense of being trouble or bothered by drug use.

Conclusions: Greater competence and empathy in the delivery of a TSF intervention were associated with better drug use and employment outcomes, while adherence was associated with employment outcomes only. Higher therapist competence was associated with lower self-report drug use, and also associated with greater self-report concern about drug use. The nature of TSF intervention may promote high levels of concern about drug use even when actual use is low. This study is suggestive, but not conclusive, that higher fidelity intervention is associated with improved treatment outcome.

Related protocols: CTN-0031, CTN-0031-A-3

Abstract:

New York State required substance use disorder (SUD) treatment programs to be 100% tobacco-free in 2008. The current study, part of the CTN platform study Managing Effective Relationships in Treatment Services (MERITS II), examined counselor (N=364) and clinical supervisor (N=98) perceptions of how extensively the tobacco-free regulation was implemented in their treatment programs, perceived accountability for implementing the regulation, and use of OASAS-provided resources to aid implementation one year after the regulation went into effect. Results showed that compared to counselors, supervisors perceive greater implementation extensiveness and report using more resources, yet they perceive lower accountability. In addition, whereas perceived accountability is significantly and positively associated with implementation extensiveness perceptions for counselors, the relationship is negative for supervisors. The association between use of resources and implementation extensiveness perceptions is significant and positive for both counselors and supervisors.

Conclusions: Implementation experiences differ between counselors and clinical supervisors, suggesting the importance of tailoring interventions to promote tobacco-free policies in SUD treatment programs. This study adds to the sparse literature on implementation research in SUD treatment, as well as providing a better understanding of the implementation of the OASAS tobacco-free regulation.

Abstract:

Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. This ancillary investigation of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031 (Stimulant Abuser Groups to Engage in 12-Step (STAGE-12)) examined associations between treatment fidelity and therapist education, experience, treatment orientation, and perceived skills. Raters scored audio-recorded TSF sessions (n=966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy, and global session performance. Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions.

Conclusions: Results from this study have implications for therapist selection, training, and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.

Related protocols: CTN-0031, CTN-0031-A-3

Abstract:

A fidelity measure was developed for use with Real Men Are Safe-Culturally Adapted (REMAS-CA), an HIV prevention intervention for ethnically diverse men in substance abuse treatment developed as an outgrowth of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018 (Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment). The aims of this ancillary investigation of data from that project were to: 1) assess the reliability of the Fidelity Rating and Skill Evaluation (FRASE); 2) measure improvement in therapist competence and adherence over time while delivering REMAS-CA; and 3) identify which modules of REMAS-CA were most difficult to deliver.

Conclusions: Results showed that the FRASE was a reliable instrument for measuring the fidelity of REMAS-CA delivery, and therapists achieved adequate adherence and competence after training, demonstrating significant improvement over time. Sessions 4 and 5 of REMAS-CA were found to contain the most challenging modules for therapists to deliver. These findings offer some guidelines for increasing counselor competence in implementing REMAS-CA for research or clinical practice. Specifically, more effort should be spent on training the counselors to implement the emotionally charged discussion and the specific skill building present in Sessions 4 and 5.

Related protocols: CTN-0018

Abstract:

Counselor emotional exhaustion has negative implications for treatment organizations as well as the health of counselors. Quality clinical supervision is protective against emotional exhaustion, but research on the mediating mechanisms between supervision and exhaustion is limited. Drawing upon data from 934 counselors affiliated with treatment programs in the National Drug Abuse Treatment Clinical Trials Network (CTN), this study examined commitment to the treatment organization and commitment to the counseling occupation as potential mediators of the relationship between quality clinical supervision and emotional exhaustion. The final ordinary least squares (OLS) regression model, which accounted for the nesting of counselors within treatment organizations, indicated that these two types of commitment were plausible mediators of the association between clinical supervision and exhaustion. Higher quality clinical supervision was strongly correlated with commitment to the treatment organization as well as commitment to the occupation of SUD counseling.

These findings suggest that quality clinical supervision has the potential to yield important benefits for counselor well-being by strengthening ties to both their employing organization as well as the larger treatment field, but longitudinal research is needed to establish these causal relationships.

Abstract:

When mental health counselors have inadequate training in substance use disorders (SUDs), effective clinical supervision (ECS) may advance their professional development. The purpose of this study was to investigate whether ECS is related to the job performance of SUD counselors. Data were obtained in person via paper-and-pencil surveys from 392 matched SUD counselor-supervisor dyads working in 27 SUD treatment organizations across the United States, all participating in the National Drug Abuse Treatment Clinical Trials Network platform study, “Managing Effective Relationships in Treatment Services” (MERITS I). Counselors rated ECS on five multi-item scales (sponsoring counselors’ careers, providing challenging assignments, role modeling, accepting/confirming counselors’ competence, and overall supervisor task proficiency). Clinical supervisors rated counselor job performance on two multi-item scales (task performance and performance within the supervisory relationship). Using mixed-effects models, the authors found that most aspects of ECS are related to SUD counselor job performance. Thus, ECS may indeed enhance counselor performance on tasks and within the supervisory relationship, which may offset the limited formal SUD training.