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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:

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:

Modern treatment options for substance use disorder are diverse. While studies have analyzed the adoption of individual evidence-based practices in treatment centers, little is known about the specific make-up of treatment strategy profiles in treatment centers throughout the United States. The current study used latent class analysis to profile underlying treatment strategies and to evaluate philosophical and structural supports associated with each profile. Using three aggregated and secondary datasets of national representative samples of substance use disorder treatment centers (N=775), including centers participating in the National Drug Abuse Treatment Clinical Trials Network, treatment strategy profiles were determined using via latent class analysis. Using multinomial logistic regression, organizational characteristics associated with each profile were also examined.

Three distinct treatment strategy profiles were found:

• Centers that primarily relied on Motivational Interviewing and Motivational Enhancement Therapy
• Centers that utilized psychosocial and alternative therapies, and
  Centers that employed comprehensive treatments including pharmacotherapy.

The multinomial logistic regression revealed that philosophical and structural center characteristics were associated with membership in the comprehensive class. Centers with philosophical orientations conducive to holistic care and pharmacotherapy-acceptance, resource-rich infrastructures, and an entrepreneurial reliance on insured clients were more likely to offer diverse interventions. All associations were significant at the .05 level.

Conclusions: The findings from this study clarify the general strategies of treatment centers and how those strategies are interconnected. Practitioners and clients should be aware of the variation in treatment center practices. Access to diverse treatment is beneficial and centers with limited offerings should consider widening their treatment, especially as the Affordable Care Act begins to increase the emphasis on integrated substance use disorder treatment with general health care practice. Centers offering medication-assisted treatment will be better able to integrate other medical services, and programs that make up the comprehensive class, which are able to offer a wide range of core and wraparound services, will be most competitive.

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:

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:

Previous research on HIV/AIDS-related services in substance use disorder (SUD) treatment has generally focused on the availability of HIV testing with less consideration of other prevention and supportive services. This study examines the adoption of HIV/AIDS-related services in treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network (CTN), with comparisons between opioid treatment programs (OTPs) and SUD treatment programs. Face-to-face interviews were conducted in 2011-2012 with administrators and clinical directors of 167 treatment programs that were members of the CTN. Dichotomous indicators measured whether programs: (1) conducted HIV risk assessments at treatment intake; (2) offered HIV education/prevention; (3) had adopted on-site HIV testing; (4) offered support groups for people with HIV/AIDS; and (5) provided on-site medical monitoring for people with HIV/AIDS (e.g., monitoring HAART compliance). HIV risk assessment (86.2%) and HIV prevention/education (79.1%) were widely adopted by treatment programs in the CTN. About 54.7% of programs offered on-site HIV testing, consisting of 30.8% of programs using rapid HIV tests and another 23.9% using non-rapid tests. Fewer programs provided HIV support groups (22.9%) and medical monitoring for people with HIV/AIDS (24.8%). Opioid treatment programs were more likely than other SUD programs to offer on-site HIV testing and support groups for people with HIV/AIDS.

Conclusions: Although most treatment programs assess risk behaviors and offer HIV prevention/education, only half of the treatment programs within the CTN provide on-site HIV testing, which is a critical strategy for ensuring that patients receive their test results. Testing services have become widespread, however, within opioid treatment programs, which may reflect heightened concerns regarding the transmission of HIV/AIDS through injection drug use for their patient population.

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:

Despite the established effectiveness of pharmacotherapies for treating opioid use disorders, implementation of medications for addiction treatment (MAT) by specialty treatment programs is limited. This research examined relationships between organizational factors and the program-level implementation of MAT, with attention paid to specific sources of funding, organizational structure, and workforce resources. Face-to-face structured interviews were conducted in 2008 to 2009 with administrators of 154 community-based treatment programs affiliated with the National Institute on Drug Abuse’s Clinical Trials Network; none of these programs exclusively dispensed methadone without offering other levels of care. Implementation of MAT was measured by summing the percentages of opioid patients receiving buprenorphine maintenance, methadone maintenance, and tablet naltrexone. Financial factors included the percentages of revenues received from Medicaid, private insurance, criminal justice, the Federal block grant, state government, and county government. Organizational structure and workforce characteristics were also measured. Implementation of MAT for opioid use disorders was low. Greater reliance on Medicaid was positively associated with implementation after controlling for organizational structure and workforce measures, whereas the association for reliance on criminal justice revenues was negative.

Conclusions: The implementation of MAT for opioid use disorders by specialty addiction treatment programs may be facilitated by Medicaid but may be impeded by reliance on funding from the criminal justice system. These findings point to the need for additional research that considers the impact of organizational dependence on different types of funding on patterns of addiction treatment practice.

Abstract:

Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these patient characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This paper explored patient caseload characteristics associated with the availability of HIV testing in a sample of substance use disorder (SUD) treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network (CTN). The authors found that almost half of programs (48%) provided onsite HIV testing for SUD patients, which is nearly double the rates reported by privately funded treatment programs and programs responding to the most recent National Survey of Substance Abuse Treatment Services. About 52% of CTN-affiliated programs offering onsite HIV testing services used a rapid test. Results also showed positive associations between the percentages of African American, Hispanic, and injection drug-using patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing at all.

Conclusions: This finding is promising and suggests that rapid HIV testing may be a feasible innovation that can be successfully adopted by SUD treatment programs. The study also suggests that many programs are responding well to the needs of at-risk populations. Treatment programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

Abstract:

Despite evidence that buprenorphine is effective, safe, and easier for patients to access than methadone, implementation of this medication for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This analysis of National Treatment Center Study (NCTS) data, which includes data collected from substance abuse treatment centers affiliated with the National Drug Abuse Treatment Clinical Trials Network (CTN), used hierarchical linear modeling to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

Conclusions: Overall, these findings suggest that (a) specific training about buprenorphine is useful, (b) counselors’ attitudes toward buprenorphine are improving over time, and (c) having a program-wide treatment philosophy that does not emphasize a 12-step model facilitates implementation. These findings are important in terms of translational research as they confirm the need to address knowledge and attitudes of frontline providers, but they also emphasize the importance of organizational culture and support for the adoption of new practices. As a critical link to the diffusion of medications, the important role of counselors and associated efforts to improve their willingness to suggest buprenorphine to their clients cannot be ignored.

Abstract:

The use of medications to treat substance use disorders (SUDs) has emerged as a potentially central part of the treatment armamentarium. In this paper from the National Treatment Center Study, the authors present data from several recent US national surveys (including two waves of onsite data collected from CTPs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN)) showing that despite the clinical promise of these medications, there has been limited adoption of pharmacotherapies in the treatment of SUDs. The data reveal variable patterns of use of disulfiram, buprenorphine, tablet naltrexone, acamprosate, and injectable naltrexone. After examining the environmental and institutional context for the adoption of pharmacotherapies, the specific organizational facilitators and barriers of medication adoption are considered. The paper concludes with a discussion of the minimal clinical and administrative guidance available to enhance adoption, the lack of client and consumer knowledge of medications that puts a brake on their adoption and availability, and the difficulties that must be surmounted in bringing new medications to market. This article describes a dysfunctional and perhaps tragic disconnect between science and practice that cannot be closed by the protracted rhetoric about the importance of the adoption of EBPs. Federal agencies and private organizations can invest in pharmacological research, but making those medications available to patients is ultimately a step governed by decisions among investors in the marketplace, the primary issue being ultimate profitability. Given the level of adoption in the data presented here, to say nothing about full-scale implementation, the commercial attractiveness of new SUDs medications is definitely open to question.

Abstract:

This presentation, a combination of three presentations given at CTN Steering Committee meetings in 2009 and 2010, begins with an overview of the goals of the University of Georgia CTN platform study. This study aims to better understand organization-level processes of adoption, implementation, and potential discontinuation of evidence-based treatment practices (EBPs); and to study the counseling workforce within CTN programs. Methodology for the study used face-to-face interviews with administrators and clinical directors of CTPs, along with mail/internet based surveys of counselors. The study looked at both publicly funded and privately funded programs, with data collection at baseline, 24 months, and 48 months. The first part of the study examined adoption of buprenorphine in opioid treatment programs, and found that CTN affiliation was significantly associated with buprenorphine adoption (CTN programs were three times more likely to adopt bup than non-CTN programs). The second part looked at buprenorphine adoption over time, finding that adoption at baseline was strongly associated with continued adoption at follow-up. The third part of the study examined adoption of alcohol pharmacotherapies in CTN and non-CTN programs, finding this time that CTN participation was not a significant predictor of tablet naltrexone adoption at baseline, but that CTN programs were three times more likely to adopt naltrexone after both 24 months and 48 months. The latest focus of the platform study was on an examination of barriers to buprenorphine or motivational incentive adoption, which found that cost was a significant factor for many programs.

The presentation concludes with a discussion of the use of the CTN as a platform for studying the counseling workforce, focusing on attitudes towards evidence-based practices, implications of research involvement for employee retention, and the role of clinical supervision in reducing emotional exhaustion and turnover.

Abstract:

Counselor attitudes toward evidence-based practices, such as motivational incentives/contingency management (MI/CM), are important in bridging the gap between research and practice. Mailed surveys from 1,959 substance abuse treatment counselors showed ambivalence toward MI/CM and strong disagreement with using monetary rewards for achievement of treatment goals. Attitudes were associated with counselors’ educational attainment, a 12-step treatment ideology, affiliation with NIDA’s Clinical Trials Network (where two multi-site clinical trials of MI/CM have been conducted, in both drug-free outpatient programs and opioid treatment programs), and working in opioid treatment programs. Exposure to MI/CM via training was more strongly associated with attitudes when counselors worked in programs that had adopted MI/CM, but overall, the extent to which counselors have received such training was relatively low. While there is substantial resistance to MI/CM, dissemination and training about the essential elements of MI/CM may enhance counselors’ receptivity toward the intervention.

This research contributes to the growing literature about the value of research networks in influencing attitudes toward evidence-based treatment practices.

Related protocols: CTN-0006, CTN-0007

Abstract:

Research on counselors’ perceptions of buprenorphine’s effectiveness and acceptability largely occurred in its initial phase of availability. The researchers hypothesized that there are measurable gaps in these attitudes, but that training is positively associated with perceived effectiveness and acceptability. To determine whether this was true, counselors in the CTN were mailed surveys measuring their perceived effectiveness and acceptability of buprenorphine, buprenorphine-specific training, program-level adoption, and professional/demographic characteristics. Substantial proportions of counselors reported that they did not know if buprenorphine was effective or acceptable, suggesting that additional dissemination efforts and training are needed. Such efforts may improve counselor attitudes, given that data indicates that greater buprenorphine-specific training was positively associated with both perceived effectiveness and acceptability.

Abstract:

This poster provides an overview of ten years of findings from the University of Georgia’s longitudinal platform study of the CTN. The study has shown a greater adoption of evidence-based practices (EBPs) in CTN-affiliated community-based treatment programs (CTPs) than in non-CTPs. CTN-affiliated counselors also hold more favorable attitudes towards EBPs than their non-CTN-affiliated counterparts.

In this poster, the specific EBPs addressed include buprenorphine, motivational incentives, and tablet naltrexone and acamprosate. The findings demonstrate the importance of a research network in promoting adoption of EBPs and fostering a higher level of receptivity to innovation adoption in general. The CTN is fulfilling its goal of increasing the quality of treatment within its constituent CTPs; future research should examine the extent to which programs are using these interventions in everyday treatment practice and assess the fidelity with which these practices are being implemented.