Blending Research and Practice: The Clinical Trials Network and Beyond

1. Blending Research and Practice: The Clinical Trials Network and Beyond Dennis McCarty, PhD Oregon Health & Science University Oregon/Hawaii Node of the Clinical Trials Network

2. 1998 IOM Report

3. IOM (1998): Recommendation 1 • The National Institute on Drug Abuse and the Center for Substance Abuse Treatment should support the development of an infrastructure to facilitate research within a network of community-based treatment programs, similar to the National Cancer Institute’s Community Clinical Oncology Program (CCOP) networks.

4. National Drug Abuse Treatment Clinical Trials Network • 17 Regional Research and Training Centers • Over 200 drug abuse treatment programs • Conducting randomized clinical trials of emerging pharmacological and behavioral therapies • 18 completed trials • Over 7,000 study participants

5. Trials of Pharmacological Therapies • Buprenorphine (Suboxone) • Bup/Nx vs Clonidine • Bup/Nx vs Methadone • Bup/Nx for adolescents • Bup/Nx for prescription opiate dependence • Osmotic-Release Methylphenidate (Concerta) • Adult smokers • Adolescents • Nicotine replacement in drug treatment

6. Results: Buprenorphine/Naloxone • Can be use safely and effectively in community treatment settings (Amass et al, 2004) • More patients stay in care and complete care with buprenorphine (Ling et al, 2005) • 7 day taper is as effective as a 30 day taper (Ling et al, under review) • Programs continue to use • Maryhaven, Columbus OH (Brigham et al, in press) • Phoenix House, NY, NY (Collins et al, in press) • Kaiser-Permanente NW, Portland, OR • 100+ maintenance patients

7. Trials of Behavioral Therapies • Lower cost motivational incentives • Motivational interviewing & enhancement therapy • Adults; pregnant women; Spanish speakers • Seeking Safety – trauma counseling for women • Reducing HIV/HCV risk behavior • Injection drug use; sex risks for women & men • Job Seekers vocational training • Brief Strategic Family Therapy • Counselor feedback • Telephone Enhancement to Improve Aftercare

8. Results: Motivational Incentives • Methadone patients reduce use of cocaine (Pierce et al, 2005) • Outpatients improve retention in care (Petry et al, 2005) • Lower cost incentives are effective • Motivational Incentives are cost-effective (Olmstead, Sindelar & Petry, in press)

9. Results: Motivational Interviewing • Motivational interviewing increased retention in care (Carroll, et al, 2006) • Effective for alcohol and drug dependent patients

10. Benefits to Participating Treatment Centers • Exposure to emerging therapies • Staff training • Participation in research • CTN trials • Additional investigations • More competitive in service awards from CSAT, HRSA, RWJF, etc

11. Examples from the Oregon/Hawaii Node • Adapt (Roseburg, OR) • HRSA Rural Health Outreach Program to integrate behavioral health care in a health clinic • State award to apply community reinforcement therapy to work with problem gamblers • ChangePoint (Portland, OR) • CSAT award to implement Matrix methamphetamine treatment model

12. Examples from the Oregon/Hawaii Node (continued) • CODA (Portland, OR) • RWJF award to participate in the Network for the Improvement of Addiction Treatment • HRSA demonstration to integrate buprenorphine into HIV primary care • Kaiser Permanente (Portland, OR) • NIDA award to study adoption of buprenorphine • NIMH award to study recovery from serious mental illness

13. Examples from the Oregon/Hawaii Node (continued) • Native American Rehabilitation Association • CSAT award to treat methamphetamine use • CDC award to reduce tobacco use • New Directions Northwest (Baker City, OR) • Participates in CJ-DATS • Oregon Practice Improvement Collaborative • Willamette Family (Eugene, OR) • CSAT award for treating adolescent women • CMHS award to integrate care for adolescent women

14. Who participates in the CTN? (McCarty et al, Psychiatric Services, 2007) • CTN-0008 Baseline Protocol Surveyed • Organizations: 106 of 112 (95%) • Treatment Units: 348 of 384 (91%) • Workforce: 3,786 of 5,334 (71%) • 1,757 counselors • 533 managers and supervisors • 511 medical staff • 908 support staff(88 missing data)

15. Types of Corporations in the CTN (vs the National Survey of Substance Abuse Treatment Services)

16. Primary Service Setting for CTN members(versus the 2003 N-SSATS)

17. Attitudes toward use of confrontation and noncompliance discharge by job category (-2 = strongly disagree; +2 = strongly agree)

18. Attitudes toward use of incentives by job category (-2 = strongly disagree; +2 = strongly agree)

19. Attitudes toward use of medications by job category (-2 = strongly disagree; +2 = strongly agree)

20. Adoption in CTN versus other treatment programs • CTN programs 5 times more likely to use buprenorphine when organizational factors controlled statistically • Treatment programs in bup trials = 46% • Other CTN treatment programs = 16% • Treatment programs not in CTN = 11%Ducharme, L. J., Knudsen, H. K., Roman, P. M., & Johnson, J. A. (In press). Innovation adoption in substance abuse treatment: Exposure, trialability, and the Clinical Trials Network. Journal of Substance Abuse Treatment. • Buprenorphine more acceptable to CTN counselors Knudsen, H. K., Ducharme, L. J., & Roman, P. M. (In press). Research network involvement and addiction treatment center staff: Counselor attitudes toward buprenorphine. The American Journal on Addictions.

21. Blending Initiative • SAMHSA-NIDA Collaboration through ATTCs • Blending products: • Buprenorphine Treatment: A Training • Short-Term Opioid Withdrawal Using Buprenorphine: Findings and strategies • SMART Treatment Planning: Utilizing the ASI • MI Assessment: Supervisory Tools for Enhancing Proficiency • Promoting Awareness of Motivational Incentives

22. MI Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) • Clinical trials and MI • Known effects on engagement and retention in controlled studies • Established efficacy in reducing substance use among alcohol and drug using clients • Need to test MI effectiveness in community agencies • Blending Team objectives and assumptions • Develop a package that promotes the use of MI • Provide tools useful to community providers • Field does not need another MI training package • MI skills erode quickly without feedback and coaching following training

23. MIA: STEP Blending Product • A tool kit for enhancing clinical proficiency in using MI • A resource for supervisors who mentor clinicians • A multi-media package of products for enhancing individual and group learning • A set of materials in the public domain that can be copied and customized to meet specific needs

24. MIA:STEP Overview • Briefing materials • Summary of the MI Assessment intervention • Results of the NIDA CTN Research • Teaching tools for enhancing and assessing MI skills • Interview rating guide and demonstration materials • Supervisor training curriculum

25. MIA:STEP The MIA:STEP package is available in several forms: • Downloadable and editable version is at: www.nfattc.org • Downloadable published pdf version • Print version plus CDs of tools and demonstration interviews available from Northwest Frontier ATTC • CD package alone available from the Mid-Atlantic ATTC

26. Concluding Comments Persistent improvements in the quality and effectiveness of care

27. Acknowledgements • Preparation of this presentation was supported through awards from • The National Institute on Drug Abuse: R01 DA018282 • The National Institute on Drug Abuse: R01 DA020832 • The National Institute on Drug Abuse: U10 DA013036 • Robert Wood Johnson Foundation: 46876 & 50165 • The Center for Substance Abuse Treatment: SAMHSA SC-05-110