Lost in Translation: Understanding and Confronting the Research to Practice Gap

1. Lost in Translation:Understanding and Confronting the Research to Practice Gap Jack B. Stein, LCSW, Ph.D. Deputy Director Division of Epidemiology, Services, and Prevention Research National Institute on Drug Abuse ASAM Conference May 2006

2. Drug Abuse & Addiction NIDA Bringing the full power of Science to bear on…

3. Priority Areas for NIDA Prevention Research (Children and Adolescents) Treatment Interventions HIV/AIDS Research Translation

4. % of Students Reporting Any Illicit Drug Use(Past Year) * * * * Denotes significant difference between recent peak year and current year.

5. % of High School Seniors Reporting Nonmedical Use of Sedatives(Past Year) * * *Denotes significant increase 2001-2005.

6. Prevalence of Drugs Among High School Seniors * Percentage reporting use in past year. **Nonmedical use.

7. Methamphetamine:Our Next Drug Epidemic?

8. Primary Methamphetamine and Primary Cocaine Treatment Admissions(1993 – 2003)

9. % of Primary Methamphetamine Treatment Admissions (Excluding Alcohol) SOURCE: CEWG January 2006 reports on State and local data

10. What Research-Based Findings/Practices Most Need to be Translated into Practice?

11. Neuroscience is revealing much about the brain and the relationship to addiction, relapse, and recovery

12. Biological Factors Interact with Environmental Factors to Produce Addiction Biology/Genes Biology/ Environment Interaction Environment DRUG Addiction

13. Decreased Brain Metabolism in Drug Abuse Patient High Control Cocaine Abuser Low Addiction is a Disease of the Brain As other diseases, it affects tissue function Decreased Heart Metabolism inHeart Disease Patient Healthy Heart Diseased Heart Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

15. Child Care Services Vocational Services Family Services Detoxification Housing / Transportation Services Intake Processing / Assessment Mental Health Services Behavioral Therapy and Counseling Substance Use Monitoring Treatment Plan Self-Help / Peer Support Groups Clinical and Case Management Pharmacotherapy Financial Services Medical Services Continuing Care Legal Services Educational Services AIDS / HIV Services 3. Effective treatment should attend to multiple needs of the individual.

16. 4. Recovery from drug addiction requires effective treatment followed by management of the disorder over time.

17. Substance Use Careers Last for Decades 1.0 .9 .8 Cumulative Survival Years from first use to 1+ years abstinence .7 Median duration of 27 years! .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25 30 Scott & Dennis, (1998)

18. Treatment Careers Last for Years 1.0 .9 .8 Cumulative Survival Years from first Tx to 1+ years abstinence .7 Median duration of 9 years and 3-4 episodes of care .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25

19. 50 - 70% 50 - 70% 40 - 60% Percent of Patients Who Relapse 30 - 50% Drug Dependence Type I Diabetes Hyper-tension Asthma Drug Dependence as a Chronic Illness O’Brien & McLellan, 1996, Lancet; McLellan et al. 2000, JAMA

20. Chronic Disease Model • Screening • Initial brief Intervention Initial Services • Prescription for Services • Patient Engagement and Retention • Recovery/Chronic Care Management Clinical Practices Engage & Sustain Assessment Therapeutic Interventions • Psychosocial Intervention (MI, MET, CBT, Contingency Mgt, CRT, 12-Step Facilitation, Structured Family/Couples) • Pharmacotherapy

21. Recovery Management Checkup • “Linkage Manager” who conducts motivational intervention and provides linkages • Motivational Intervention: • Provide personalized feedback • Recognize problem and consider return to treatment • Address existing barriers to treatment - Schedule assessment Dennis, Scott, Funk (2003)

22. Median of 376 vs. 600 days Median of 376 vs. 600 days, Wald=5.2, p<.05 RMC (64% readmitted) H1: RMC Clients will return to treatment sooner 1.0 .9 .8 Percent to be Readmitted .7 .6 .5 Control (51% readmitted) .4 .3 OR: 1.34 X2(1)=6.8, p<.01 .2 .1 0.0 0 90 180 270 360 450 540 630 720 Days to Readmission Dennis, Scott, Funk (2003).

23. 5. Treatment must last long enough to produce stable behavioral changes.

24. CREST Completers + Aftercare CREST Completers + Aftercare No Treatment No Treatment CREST Dropouts CREST Dropouts CREST Completers CREST Completers Aftercare Matters 7. Continuity of care is essential. Delaware Correctional System 3 Years Post Work Release * Arrest-Free * Drug-Free * * * * p < .05 from Comparison Martin, Butzin, Saum, & Inciardi (1999)

25. Medications to Keep an Eye On • Topiramate: alcohol, cocaine, nicotine • Marinol+rimonabant: marijuana • Depot naltrexone: opiate, alcohol • Bupropion, Vigabatrin, Topiramate, Modafinil: methamphetamine

26. 11. Planning should include a focus on HIV/AIDS and other infections.

27. Expanded HIV Testing Improves Survival Rates and is Cost Effective Paltiel, 2006; Sanders, 2006

28. Medication Adherence Adolescent Treatments Cognitive-Behavioral Treatment Combined Pharmacotherapies and Behavioral Therapies Complementary and Alternative Treatments Community Reinforcement Approach Smoking Cessation Contingency Management Treatments Dialectical Behavioral Therapy Drug Counseling Family Treatments Group Behavior Therapy HIV Risk Reduction Motivational Interviewing/Enhancement Seeking Safety (PTSD) Work Therapy Behavioral Treatments with Strong Scientific Support

29. Modafinil Improves CBT Therapy Results in Cocaine Addiction Dackis, et al., 2006

30. NID A NATIONAL INSTITUTE ON DRUG ABUSE National Drug Abuse Treatment Clinical Trials Network A research infrastructure of 17 RRTCs & 150 CTPs across 34 States, and Puerto Rico

31. Drug Abuse Treatment Core Components and Comprehensive Services Motivational Interviewing TELE Child Care Services Family Services Vocational Services Motivational Incentives Intake Processing / Assessment Housing / Transportation Services Mental Health Services Abstinence-Oriented Substance Abuse Counseling Supportive Group and Individual Counseling Pharmacotherapy Substance Use & Urine Monitoring Clinical & Case Management Continuing Care Financial Services Medical Services Legal Services Educational Services Buprenorphine Detox AIDS / HIV Risk Services Treatment Plan Self-Help (AA, NA) Meetings

32. New CTN Protocols • Health consequences of buprenorphine/naloxone and methadone • Prescription Opioid Addiction Treatment • ADHD and Substance Use Disorders • 12-Step Facilitation

33. The Challenge of Implementation

34. Are We Speaking the Same Language? • Technology Transfer • Research Diffusion • Dissemination • Adoption • Replication • Implementation • Science to Services • Blending

35. A Conceptual Framework for Technology Transfer Dissemination Adoption Implementation

36. An evidence-based program is one thing…. Implementation of an evidence-based practice is a very different thing.

37. The Translation Bottleneck Bench Bedside Community

38. Quality of Health Care Delivery Senile cataract Breast cancer Prenatal care Low back pain CAD Hypertension Congestive heart failure Cerebrovascular disease COPD Depression Orthopedic conditions Osteoarthritis Colorectal cancer Asthma Benign prostatic hyperplasia Hyperlipidemia Diabetes mellitus Headache UTI Community-acquired pneumonia STDs Dyspepsia and peptic ulcer disease Atrial fibrillation Hip fracture Alcohol dependence 0 20 40 60 80 100 Source: McGlynn, E.A., NEJM, 348, pp. 2635-2645, June 26, 2003

39. (N = 171 Administrators) Roman, et al., Treatment Innovations in Publicly Funded Substance Abuse Treatment Centers: A Preliminary Report from the Field: Presentation at CTN Steering Committee Meeting, 2002. Adoption of Treatment Innovations

40. Implementation Barriers • Off the shelf interventions often not readily accepted. • May not work in real-life settings w/o modifications. • Not enough attention to organizational/systems level issues. • Plastic wrap on manuals often too tight to open.

41. Implementation research is still limited

42. “We are faced with the paradox of non-evidenced based implementation of evidence-based programs.” -Drake, Gorman, & Torrey (2002)

43. Diffusion Theory Everett Rogers

44. The QWERTY keyboard Designed in 1873 to minimize jamming

45. The Dvorak Keyboard (1932) Quicker to learn More efficient

46. The “S” Curve Late Adopters Larger farms Higher incomes More education % of Adoption Take-Off Early Adopters Time Source: Ryan & Gross (1943)

47. Adopter Categorization Early Majority=34% Late Majority=2.5% Early Adopters=13.5% Laggards=16% Innovators=2.5% x-2sd x-sd x x+sd Source: Rogers (2003)

48. Key Elements for Adoption of an Innovation • Relative advantage • Compatibility • Complexity • Trialability • Observability

49. “…the best candidate for rapid adoption would be an evidence-based treatment that was simple, was similar with previous practice, had clear advantage, could be tried out temporarily, and was readily observable.” -Henggeler, Lee, & Burns (2002) Clinical Psychology-Science and Practice

50. Early Technology Transfer Research at NIDA • “Reviewing the Behavioral Science Knowledge Base on Technology Transfer” • Monograph Number 155 (Backer, David, & Soucy, 1995)