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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:

There is growing concern that the results from randomized controlled trials (RCTs) might not generalize to real world settings, particularly in the context of RCTs of treatments for substance use disorders (SUDs). Limitations in generalizability of the findings from RCTs pose major clinical and policy concerns because RCTs are considered the most accepted study design for choosing evidence-based practices. The randomized study design does not necessarily ensure external validity, which means that the findings of an RCT may not be applicable to all individuals for whom treatment or intervention is intended. Individuals who volunteer to participate in RCTs are typically different from those who refuse to participate. Furthermore, strict eligibility criteria are likely to make the findings less applicable to subgroups who are excluded from trials.

This study had two main aims: 1) to estimate sample treatment effects and the population effects of RCTs of SUD treatment, and 2) to examine the treatment effect heterogeneity by subgroups that are under- or over-represented in a set of RCTs conducted by the NIDA Clinical Trials Network.

Statistical weighting was used to re-compute the effects from ten CTN RCTs such that the participants in the trials had characteristics that resembled those of patients in the target populations. Three outcomes of SUD treatment were examined: retention, urine toxicology, and abstinence. The RCT sample treatment effects were weighted using propensity scores representing the conditional probability of participating in RCTs.

Weighting the samples changed the significance of estimated sample treatment effects. Most commonly, positive effects of trials became statistically non-significant after weighting (three trials for retention and urine toxicology, and one trial for abstinence); but also, non-significant effects became significantly positive (one trial for abstinence), and significantly negative effects became non-significant (two trials for abstinence). There was suggestive evidence of treatment effect heterogeneity in subgroups that are under- or over-represented in the trials, some of which were consistent with the differences in average treatment effects between weighted and unweighted results.

Conclusions: The findings of randomized controlled trials (RCTs) for substance use disorder treatment do not appear to be directly generalizable to target populations when the RCT samples do not adequately reflect the target populations and there is treatment effect heterogeneity across patient subgroups. Results from this study provide a first insight into whether and how deviations in RCT sample representativeness from target populations influence the observed outcomes of SUD RCTs. It is critical for future CTN studies to place greater emphasis on external validity of RCTs, particularly because a primary goal of the NIDA CTN was to provide data on SUD treatment that can be disseminated in usual care settings.

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:

The field of substance use disorder (SUD) treatment suffers from a “modality mismatch,” in which researchers primarily examine individual therapies even while real-world psychosocial clinicians primarily facilitate groups (especially open groups).

Although understandable reasons exist for this state of affairs, group therapy is not diminishing anytime soon; moreover, clinicians may be ill-equipped at using evidence-based treatments (EBTs) in group format, given limited training along with non-trivial structural differences between modalities.

This one-hour webinar included a review of SUD group therapy research and clinical resources (including two CTN studies), with a focus on facilitators and barriers for using EBTs in group format.

Presenter Dennis C. Wendt, PhD, is a postdoctoral research fellow with the Department of Psychiatry and Behavioral Sciences at the UW School of Medicine.

Additional Resources:

• Download slides (pdf)
• Download handout (pdf)

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:

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:

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 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.

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:

Substance abuse is a leading cause of death and disability throughout the world. The mission of the National Institute on Drug Abuse (NIDA) is to lead the United States in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components: (a) strategic support of research across a broad range of disciplines and (b) rapid, effective dissemination of research results that can improve prevention and treatment efforts, with potential to inform policy. The NIDA National Drug Abuse Treatment Clinical Trials Network (CTN) and the Blending Initiative are critical elements of this strategy, and the social work field is poised to use these resources to expand its role in the dissemination and implementation of NIDA’s mission.

The article describes the CTN and Blending Initiatives in general, the CTN Dissemination Library, CTN Data Share, and each of the Blending Initiative training products developed to date. NIDA, the Blending Initiative, and the CTN offer great promise toward implementation of evidence-based practices, and social workers are encouraged to seize every opportunity to initiate and remain engaged in substance abuse treatment, research, and training activities.

Abstract:

This secondary analysis of data from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0008, “Assessment of the CTN: A Baseline for Investigating Diffusion of Innovation,” examined the relative contribution of providers’ professional affiliation (medical vs. non-medical), involvement in research, and training needs for associations with endorsement of the following evidence-based practices (EBPs): (1) pharmacological — buprenorphine treatment and (2) psychosocial – Cognitive Behavioral Therapy (CBT). As part of CTN-0008, 571 substance abuse treatment providers (medical, social workers, psychologists, and counselors) were surveyed. After multivariate linear regression models were used to analyze the cross-sectional survey data, results found that medical providers and providers with previous research involvement more strongly endorsed the effectiveness of buprenorphine over CBT. Compared to medical providers, psychosocial providers more strongly endorsed CBT. There was a positive association between needing training in rapport with patients and endorsement of buprenorphine and a negative association with CBT. There was also a positive association between needing training in behavioral management and needs assessment and endorsement of CBT.

Conclusions: The current findings revealed that providers’ specializations, as well as their involvement in research, are critical to their perceptions about various practices. Therefore, provider training should explicitly address issues of evidence regardless of providers’ education, job title, and knowledge level. Greater emphasis ought to be place on training all providers how to practice in transdisciplinary teams so that knowledge about pharmacological and psychosocial practices is elevated among all professionals.

Related protocols: CTN-0008

Abstract:

This one-day conference was designed to benefit front-line clinical staff delivering addiction treatments in Texas. Speakers presented sessions in the morning on Motivational Interviewing (MI) with a focus on shifting talk to action, an introduction to Acceptance and Commitment Therapy (ACT) and review of its effectiveness, and a review of pharmacological treatments for addictive disorders. Afternoon breakout sessions for MI and ACT expanded upon information discussed in the morning sessions and attendees engaged in experiential learning and practice.

View conference agenda.

Presentations:

Advanced Motivational Interviewing: Shifting from Talk to Action, Scott Walters, PhD

An Introduction to Acceptance and Commitment Therapy (ACT) with a Focus on Opioid Dependent Patients (morning session | afternoon session), Angela Stotts, PhD.

Pharmacotherapy for Addictive Disorders, Sidarth Wakhlu, MD