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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:

Although substance abuse treatment programs are an important point of contact to provide health services to diagnose, treat and prevent transmission of hepatitis B (HBV) and hepatitis C (HCV) viral infection, little is known about the availability of these services in substance abuse programs. This presentation reports on a study that evaluated the prevalence and spectrum of HBV and HCV services offered by drug treatment programs in the U.S. A questionnaire-based survey of drug treatment programs within the National Drug Abuse Treatment Clinical Trials Network was conducted as part of protocol CTN-0012 (“Characteristics of Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C Viral Infections, and Sexually Transmitted Infections in Substance Abuse Treatment Programs”). Completed questionnaires were received from 269 (84.3%) of the 319 program administrators. Although 78.7% of programs reported that they offered ongoing hepatitis training for clinical staff, only a minority of programs offered testing for HBsAg (37.7%), HBsAb (36.7%), HBcAb (27.7%), HBV DNA (7.8%), HCV antibodies (52.9%), HCV qualitative (10.1%) or quantitative (8.9%) PCR, and HCV genotyping (11.6%). Hepatitis A and B vaccinations were offered by 68.3% of programs, either on site (19.3%) or via referral (49.1%). Programs having clear guidelines for hepatitis testing were significantly more likely to offer each of the hepatitis tests as compared with those that did not have clear guidelines. Only 28.9% of programs offered HCV treatment either on-site or via referral.

Despite the importance of substance abuse in sustaining the hepatitis epidemics in the U.S., many substance abuse treatment programs do not offer comprehensive HBV, HCV and hepatitis vaccination services. Public health interventions to improve access to hepatitis testing, treatment and prevention for substance abusers are needed.

Abstract:

This poster discusses the results of a survey done as part of protocol CTN-0012 (“Characteristics of Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C Viral Infections, and Sexually Transmitted Infections in Substance Abuse Treatment Programs”), emphasizing the perspective of state substance abuse and health departments in relationship to the treatment programs within their jurisdiction for three infection groups: HIV/AIDS, Hepatitis C virus, and sexually transmitted infections. State substance abuse and health departments were compared regarding priorities, written guidelines and availability of funding for 8 selected services for the 3 infections (24 comparisons). In addition, clarity of guidelines and availability of funding for the 8 services, as reported by administrators and clinicians at treatment programs offering these services were compared with guidelines and funding as reported by the states. Surveys were received from 48 states and DC (96%) representing 46 substance abuse and 42 health departments. The response rate from treatment program administrators and clinicians was 269 (84%) and 1723 (78%), respectively. There was general agreement between states and the two departments within the states regarding priorities and availability of funding (19 of 24 comparisons). While most states had guidelines for infection-related services, clarity of guidelines as expressed by treatment program administrators and clinicians was less than optimal. For funding, treatment program administrators indicated less availability than the states for all 24 comparisons, 19 of which were statistically significant. While states appear generally to have their priorities, guidelines and funding in place, the mosaic that constitutes the healthcare delivery system may be too complex for the treatment programs to access most efficiently.

Abstract:

Smoking rates among addiction treatment clients are 3-4 times higher than those of the general population. Recent studies indicate that ceasing tobacco use during treatment may improve recovery outcomes. Across the United States, publicly funded addiction treatment programs vary widely in terms of their tobacco policies and tobacco cessation services offered to clients. This study recruited 24 programs from a random sample of publicly funded programs participating in the NIDA Clinical Trials Network. Semi-structured interviews were administered by phone to program directors. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.

While all directors expressed interest in helping clients to quit smoking, they cited numerous barriers to implementing tobacco policies and services. These included smoking culture, client resistance, lack of resources, staff smoking, and environmental barriers. Directors also cited several factors that they believed would support tobacco cessation. These included financial support, enhanced leadership, and state mandates against smoking in addiction treatment programs.

Conclusions: Addiction treatment programs are beginning to place more emphasis on tobacco cessation during treatment. However, furthering this goal requires substantial infrastructural and cultural change. These qualitative study findings may help encourage Single State Agencies (SSAs) to support publicly funded addiction treatment programs in their tobacco cessation efforts. In order to maximize effectiveness, state-level policies regarding tobacco cessation during treatment should be informed by ongoing dialogue between service providers and SSAs.

Abstract:

Despite considerable empirical evidence that psycho-social interventions improve addiction treatment outcomes across populations, implementation remains problematic. A small body of research points to the importance of research network participation as a facilitator of implementation; however, studies examined limited numbers of evidence-based practices. To address this gap, the present study examined factors impacting implementation of motivational interviewing (MI). This study used data from a national sample of privately funded treatment programs (n=345) and programs participating in the NIDA Clinical Trials Network (CTN) (n=156). Data were collected via face-to-face interviews with program administrators and clinical directors (2007-2009). Analysis included bivariate t tests and chi-square tests to compare private and CTN programs, and multivariable logistic regression of MI implementation.

A majority (68%) of treatment programs reported use of MI. Treatment programs participating in the CTN (88.9%) were significantly more likely to report use of MI compared with non-CTN programs (58.5%; P<0.01). CTN programs (82.1%) also were more likely to use trainers from the Motivational Interviewing Network of Trainers as compared with private programs (56.1%; P<0.05). Multivariable logic regression models reveal that CTN-affiliated programs and programs with a psychiatrist on staff were more likely to use MI. Programs that used the Stages of Change Readiness and Treatment Eagerness Scale assessment tool were also more likely to use MI, whereas programs placing greater emphasis on confrontational group therapy were less likely to use MI.

Conclusions: These findings suggest the critical role of research network participation, access to psychiatrists, and organizational compatibility in the adoption and sustained use of MI for the treatment of substance use disorders. Results suggest that as treatment programs begin the implementation process, special attention should be paid to creating an organizational climate receptive to innovation, and also the critical infrastructure necessary to facilitate implementation of psychosocial EBPs such as MI.

Abstract:

Internal process improvements embedded within the Network for Improvement of Addiction Treatment (NIATx) program are promising innovations for improving substance use disorder (SUD) treatment performance, such as engagement and retention. To date, few studies have examined the variables that may increase diffusion and implementation of NIATx innovations. This study investigates organization characteristics associated with SUD treatment center utilization of NIATx process improvements in a sample of 458 treatment programs, including programs participating in NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN). Overall, 19% had utilized NIATx process improvements. After statistically controlling environmental factors, five organizational variables were associated with the likelihood that treatment centers used NIATx processes. Organization size, administrative intensity, membership in a provider association, and participation in the CTN were positively associated with the odds of utilizing NIATx processes, while the association for the level of slack resources was negative.

Conclusions: From a practical perspective, this study illustrates that the willingness of treatment centers to undertake process improvements through NIATx processes can be explained to a large extent by organizational factors. Policies and related supportive efforts may be required to facilitate diffusion and implementation of NIATx processes to affect SUD treatment center performance and capacity.

Abstract:

Low- and middle-income countries (LMIC) lack the research infrastructure and capacity to conduct rigorous substance abuse and mental health effectiveness clinical trials to guide clinical practice. A partnership between the Florida Node Alliance of the United States NIDA Clinical Trials Network and the National Institute of Psychiatry in Mexico was established in 2011 to improve substance abuse practice in Mexico. The purpose of this partnership was to develop a Mexican national clinical trials network of substance abuse researchers and providers capable of implementing effectiveness randomized clinical trials in community-based settings.

A technology transfer model was implemented and ran from 2011-2013. The Florida Node Alliance shared the “know how” for the development of the research infrastructure to implement randomized clinical trials in community programs through core and specific training modules, role-specific coaching, pairings, modeling, monitoring, and feedback. The technology transfer process was bi-directional in nature in that it was informed by feedback on feasibility and cultural appropriateness for the context in which practices were implemented. The Institute, in turn, led the effort to create the national network of researchers and practitioners in Mexico and the implementation of the first trial. A collaborative model of technology transfer was useful in creating a Mexican researcher-provider network that is capable of changing national practice in substance abuse research and treatment. Key considerations for transnational technology transfer are presented.

Abstract:

The association between sexual HIV risk and substance use is well documented, giving providers (e.g., counselors or physicians) of substance abuse treatment an opportunity to address HIV education and prevention. This study identified: (1) providers’ HIV prevention practices, (2) barriers, and (3) promoters to offering HIV prevention in substance abuse treatment. Semistructured qualitative interviews with one director, one medical provider, and four counselors, from each of six outpatient clinics affiliated with the National Drug Abuse Treatment Clinical Trials Network (CTN) (N=36) were transcribed and coded according to thematic content analysis. Providers’ practices included: (1) recommending condoms, (2) explaining HIV transmission, (3) HIV testing, and (4) assessing risk. Barriers included: (1) believing that clients know enough about HIV, (2) believing that clients are not at risk, (3) lacking information, (4) outdated training (i.e., >5 years ago), (5) HIV stigma, and (6) avoidance. While some providers recommended condoms and HIV testing, many avoided discussing HIV.

Conclusions: HIV prevention practices in substance use treatment vary among clinics and providers. These results suggest a need for training to improve understanding of HIV transmission, effective counseling practices, and to build capacity for HIV testing or linkages with HIV service agencies.

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:

In 2008, the state of New York required substance use disorder treatment organizations to be 100% tobacco-free. This study analyzed data from NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) platform study, Managing Effective Relationships in Treatment Services (MERITS II), to examine clinicians’ perceptions of the implementation extensiveness of the tobacco-free practices approximately 10–12 months (Time 1) and 20–24 months (Time 2) post regulation and investigated whether clinicians’ commitment to change and use of provided resources at Time 1 predicts perceptions of implementation extensiveness at Time 2. Clinicians (N=287) noted a mean implementation of 5.60 patient practices (0–10 scale), 2.33 visitor practices (0–8 scale), and 6.66 employee practices (0–12 scale) at Time 1. At Time 2, clinicians perceived a mean implementation of 5.95 patient practices (no increase from Time 1), 2.89 visitor practices (increase from Time 1), and 7.12 employee practices (no increase from Time 1).

Conclusions: Two main conclusions can be reached from the findings. First, perceived implementation extensiveness of the tobacco-free practices for patients, visitors, and employees at Time 1 is limited and only perceptions of visitor practices increase significantly at Time 2. Additionally, clinicians’ commitment to change predicts unique variance in perceptions of implementation extensiveness over time for visitor and employee practices but not patient practices. By contrast, clinicians’ use of OASAS-provided resources is a unique predictor of perceived implementation extensiveness of patient, visitor, and employee practices over time. The NYS OASAS 100% tobacco-free regulations in SUD treatment programs provides a unique opportunity to study clinicians’ perceptions of the implementation extensiveness of various practices of the regulations over time.

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:

The National Drug Abuse Treatment Clinical Trials Network (CTN) is a practice-based research network that partners academic researchers with community based substance use disorder (SUD) treatment programs designed primarily to conduct effectiveness trials of promising interventions. A secondary goal of the CTN is to widely disseminate results of these trials and thus improve the quality of SUD treatment in the U.S. Drawing on data from 156 CTN programs, this study examined the associated between involvement in CTN protocols and overall treatment quality measured by a comprehensive index of 35 treatment services. Negative binomial regression models show that treatment programs participating in a greater number of CTN protocols had significantly higher levels of treatment quality, an association that held after controlling for key organizational characteristics. Given that protocol participation was positively associated with quality of treatment, the question remains about how to successfully translate this knowledge and skill base to community-based treatment programs that are not directly involved in clinical research. The CTN has undertaken a number of dissemination initiatives to do just that, including the NIDA/SAMHSA Blending Initiative and the CTN Dissemination Library, though there have been few studies examining the direct impact of these dissemination activities on the quality of treatment services within and outside the CTN.

Conclusions: At their core, practice-based research networks, such as the CTN, offer community based clinicians the opportunity to bring innovation to and to address problems encountered in everyday treatment practice. They also provide an opportunity to identify barriers to implementation and to tailor implementation strategies to meet the real world needs of community-based treatment programs. However there are significant strides to be made in disseminating knowledge, skills, and training to programs that do not actively participate in clinical research in the wider treatment community. These findings contribute to the growing body of research on the role of practice-based research networks in promoting health care quality.

Abstract:

This study, based on data from the Managing Effective Relationships in Treatment Services (MERITS II) project, an ancillary study of the National Drug Abuse Treatment Clinical Trials Network (CTN), measured substance use disorder clinicians’ perceptions regarding the implementation extensiveness of the Office of Alcohol and Substance Abuse Services (OASAS) tobacco-free regulation, passed in New York State in July of 2008, at three time-points and across organizations with varying characteristics. Repeated cross-sectional data were collected from clinicians approximately 4 months pre-regulation (time 0, n=362), 10-12 months post-regulation (time 1, n=462), and 20-24 months post-regulation (time 2, n=509). Clinician perceptions of implementation extensiveness (number of required policies in effect), use of tobacco cessation-related intake procedures, and use of guideline recommended counseling for treating tobacco dependence are significantly greater at time 1 and time 2 compared to time 0. Additionally, differences are found in perceived implementation extensiveness based on hospital-based status, profit status, and level of care offered, although the pattern of effects differed some over the three time-points under investigation.

Conclusions: In conclusion, New York State offers a unique context for studying the implementation extensiveness of a mandatory tobacco-free regulation. These findings suggest that the OASAS tobacco-free regulation is associated with changes in tobacco policies in SUD treatment organizations over time and greater reported use of clinical practice behaviors to support tobacco cessation. In addition, it appears as if the regulation lessens differences in treatment provision between clinicians who work in hospital- versus non-hospital-based settings, for-profit versus non-profit organizations, and settings offering inpatient only, outpatient only, and both outpatient and inpatient care. These are important findings given the difficult challenges associated with sustaining organizational change over time and barriers to treating tobacco dependence in SUD treatment, though there is additional work to be done to bring about regulatory change and align clinical practice behaviors to support tobacco cessation in New York.

Abstract:

On July 24, 2008, New York State (NYS) became the first state to require all state-funded or state-certified substance use disorder (SUD) treatment organizations to be 100% tobacco-free and offer tobacco cessation (TC) treatment. This study used a quasi-experimental, non-equivalent control group design with a pretest and posttest to examine the effect of the NYS tobacco-free regulation on three clinical practice behaviors (use of TC-related intake procedures, use of guideline recommended counseling for TC, and pharmacotherapy availability) in a diverse sample of SUD treatment programs, all participating in the National Drug Abuse Treatment Clinical Trials Network (CTN) platform study, “Managing Effective Relationships in Treatment Services (MERITS). Repeated cross-sectional data were collected from NYS counselors (experimental group, from the MERITS II study) and non-NYS counselors (control group, from MERITS I) approximately 4 months pre-regulation and 10-12 months post-regulation. Using mixed-effects models, results at pre-regulation indicate no group differences in the three clinical practice behaviors. However, significant post-regulation effects were found such that the experimental group reports greater use of TC-related intake procedures, guideline recommended counseling, and availability of pharmacotherapy than the control group. Additionally, the experimental but not the control group shows increases in all three clinical practice behaviors from pre-regulation to post-regulation.

Conclusions: Two main conclusions can be reached from these findings. First, the New York State tobacco-free regulation had a positive effect on important clinical practice behaviors related to treating tobacco dependence. And second, although the passage of the regulation is associated with increased use of tobacco cessation clinical practice behaviors, there is much opportunity for improving the use of these practices. With increasing numbers of states considering tobacco-free regulations in SUD treatment, the lessons learned from the New York State experience should prove valuable in efforts to effectively implement regulatory change in other programs.