ATTC Network Efforts to Combat Resistance to MAT (2011 AHSR Conference)

Panel Introduction

Closing the gap between research and practice: Successful technology transfer strategies in combating

resistance to medication‐assisted treatment

Addiction Health Services Research Conference 2011Olivia Ryan, M.P.A.

University of Missouri – Kansas CityATTC National [email protected]

• About the Addiction Technology Transfer Center (ATTC) Network

• Setting the Context: Where are we with MAT?

• NIDA/SAMHSA Blending Initiative Overview: A focus on medication‐assisted treatment

• MAT in Special Populations

Panel Agenda

3

The ATTC Network 2007‐2012

The ATTC Network’s Vision

Southern Coast

All professionals who address the needs of individuals with, or who are at risk of having, substance use disorders will utilize effective, culturally responsive practices that lead to improved healthcare and long-term health and wellness.

SAMHSA’s Plan for 2011-14SAMHSA’s 8 Strategic Initiatives

1) Prevention of Substance Abuse and Mental Illness

2) Trauma and Justice

3) Military Families

4) Recovery Support

5) Health Reform

6) Health Information Technology

7) Data, Outcomes, and Quality

8) Public Awareness and Support

Our Role in SAMHSA’s Plan

• The ATTC Network conducts numerous efforts across SAMHSA’s eight Strategic Initiatives

• The ATTC Network is a stable infrastructure to address the objectives outlined by SAMHSA in the “Leading Change” plan

ATTC Activities related to each initiativeSeptember 2009-2010

*Health Information Technology

*

What is Technology Transfer?

Southern Coast

What is Technology Transfer?

Copyright 2010 ATTC Network





Panel Agenda

Setting the Context: Where are we with MAT?

Addiction Health Services Research Conference 2011

Traci Rieckmann, Ph.D.Oregon Health & Sciences University

Northwest Frontier [email protected]

Setting the Context – Agenda

Background MAT Implementation ATTC MAT Resources

Definition: MAT is the use of medication, combined with counseling and behavioral therapies, to provide a whole patient approach to the treatment of substance use disorders. (http://www.dpt.samhsa.gov )

Use of pharmacotherapy for drug dependence and detoxification is expanding

Research continues to confirm that the use of MAT provides better outcomes, and reductions in drug use, mortality rates, and criminal activity (Rieckmann et al., 2010; Woody et al., 2008; Saxon & McCarty, 2005; Greenfeld & Fountain, 2000).

BACKGROUND

MAT Effectiveness Published by SASMHA as Treatment Improvement Protocol

(TIP) 43, MAT is a widely recognized evidence based practice

Research indicates that MAT is effective for opioid dependent patients seeking treatment along with counseling (Marchandet al., 2011).

MAT is cost effective & provides more health benefits than providing treatment without medication (M. Connock et al., 2007)

BACKGROUND

Agonist therapy or MAT, has been hailed as the most effective treatment, especially when combined with psychotherapy (Barnett et al., 2001).

MAT Goals:• Reduce symptoms and signs of withdrawal• Reduce or eliminate craving• Block effects of alcohol or illicit opioids• Restore normal physiology• Promote psychosocial rehabilitation and non‐drug lifestyle

Research to date confirms lower risk of abuse, overdose, and toxicity and diminished withdrawal symptoms when using medication assisted treatment (Burns et al., 2009).

BACKGROUND

Use & Effectiveness

Approved MedicationsMedications for Alcohol Dependence Naltrexone (ReVia®, Vivitrol®, Depade®) Disulfiran (Antabuse®) Acamprosate Calcium (Campral®) Medications for Opioid DependenceMethadone Buprenorphine (Suboxone® and Subutex®) Naltrexone

BACKGROUND

Clinical trials have demonstrated efficacy of MATs for opioid dependent patients• Clinical trial of Buprenorphine (Bickel et al., 1988)• CTN 0003: Suboxone taper: a comparison of two schedules (Amass et al., 2004; Ling et al., 2010).

Physician Clinical Support System (Fiellin et al., 2008).• PCSS‐B

BACKGROUND

MAT Trials

MAT IMPLEMENTATION

Comprehensive Tx PlanPsychosocial Treatments

MedicationsReduce symptoms and signs of withdrawalReduce or eliminate cravingBlock effects of alcohol or illicit opioidsRestore normal physiologyPromote psychosocial rehabilitation and non‐drug lifestyle

MAT IMPLEMENTATION

ATTC Network Definition of ImplementationIncorporating an innovation into routine practice. Implementation ideally includes a range of strategies designed to address individual, organizational, and systemic characteristics (e.g., skills training, administrative buy‐in, and policy changes).

Barriers to Implementation Gap between research and practice

• Adoption of medication to treat SUDs remains slow despite evidence of effectiveness

• There is a critical need to merge the gap between research and practice with MAT

Organizational factors• Two‐thirds of organizations' efforts to implement change fail (Damschroder et al., 2009).

• Implementation requires an active change process aimed to achieve individual and organizational level use of the intervention as designed (Damshroder at al., 2009).

MAT IMPLEMENTATION ‐ BARRIERS

Barriers to Implementation

Workforce resistance• Less than 45% of US substance use disorder treatment programs are found to prescribe any single SUD medication (Roman et al., 2011).


Gap Between Research and Practice

According to SAMHSA’s National Survey of Substance Abuse Treatment Services, only 22.3% of patients seeking treatment for a SUD were receiving medication assisted treatment‐Methadone and Buprenorphine (Substance Abuse and Mental Health Services Administration, N‐SSATS Report, 2008).

Similarly – The National Treatment Center Studies from UGA found that 14.3% of programs reported using Buprenorphine,10.7% use Methadone, 15.2% use Naltrexone, and 16.5% use Disulfiram, from a 2007 study (Knudsen et al., 2010).

BARRIERSMAT IMPLEMENTATION ‐ BARRIERS

Organizational Factors as Barriers

Agencies with national accreditation (Ducharme et al., 2008; Knudsen et al., 2010).

Agencies that adhere to a 12‐step model Focus on individual, not organizational

‐Much of the research on implementation of evidence‐based SUD interventions emphasizes individual counselor training, with less attention on the influence of organizational factors (Damschroder et al., 2011).


Overcoming Organizational Barriers

Characteristics of the medication and societal attitudes influence the adoption of medication assisted treatment (Knudsen et al., 2007; Mark et al., 2009; Ducharme et al., 2009; Rieckmann et al., 2011).

State regulations may create or remove barriers to the adoption of MATs by community‐based treatment provider organizations (Ducharme et al., 2008).

Persons endorsing a 12‐step model perceived less interest in addiction medication (McGovern et al., 2004).


Workforce Barriers Environmental pressures including market and

regulations, treatment philosophy, resource constraints, service objectives, and patient mix influence MAT adoption (Wallack et al., 2010; Scott et al., 1993).

Lack of knowledge from physicians about medication assisted treatment (Mark et al., 2003).

Complexity of treatment, costs, regulatory limits Differing physician beliefs: not enough evidence Need for physician training


Overcoming Workforce Barriers Influence from society and other providers Specific training leads to greater acceptabilityWhile physician knowledge of effectiveness and

an organization’s positive attitude toward medications are important, physicians are dependent on structural and procedural supports in their office settings to allow for MATs (Wallacket al., 2010).


Achieving MAT ImplementationWhere to start: Listening and education

• Do staff understand the need or gap in services?

• Do staff understand the clinical implications of the change on their work?

• Will clients be different from the ones we treat now?

• Does staff have the requisite knowledge, tools, and equipment to be successful?

MAT IMPLEMENTATION ‐ SUCCESS

What is Needed for Successful MAT Implementation

Research indicates that training improves staff attitudes and beliefs (Johnson et al., 2005; Knudsen et al., 2005; Rieckmann et al., 2011).

Research also suggests that experience with medications (for counselors) leads to more positive perspectives (Thomas et al., 2003; Knudsen et al., 2005).

Research network participation helps promote positive attitudes toward EBPs (Campbell et al., 2003; Levant et al., 2008).

MAT IMPLEMENTATION ‐ SUCCESS

ATTC Strategies to Accelerate the Use of MAT

ATTC NETWORK RESOURCES

Examples of Product Development Strategies• Curricula• Marketing/Outreach Materials

Examples of Educational Strategies• Online Courses, Regional Presentations & Trainings• Learning Collaboratives

Examples of Organizational Change Strategies• Process Improvement • Coaching

Examples of Systems Transformation Efforts• Collaborations with state officials to address varying state requirements, regulations and funding

Conclusion

The uptake of new treatment protocols cannot always be guaranteed based on evidence proving the effectiveness of

those protocols.

Healthcare fields can often be reluctant to approach new treatment methods resulting in a need for outreach efforts to

ensure that the treatment field understands the importance of applying new methods to practice.





Panel Agenda

NIDA/SAMHSA Blending Initiative

Overview: A Focus on Medication‐Assisted Treatment


Thomas E. Freese, Ph.D.University of California – Los AngelesPacific Southwest [email protected]

Beth Rutkowski, M.P.H.University of California – Los AngelesPacific Southwest [email protected]

NIDA/SAMHSA Blending Initiative

According to Webster’s Dictionary definition

To Blendmeans: a. combine into an integrated whole; b. produce a harmonious effect

http://www.merriam‐webster.com/dictionary/blend

What is the Blending Initiative?• GOAL: To move important scientific findings into mainstream addiction treatment

• Developed in 2001, NIDA and SAMHSA’s Center for Substance Abuse Treatment came together to work on a common vision:– Improve substance use disorder treatment and accelerate the dissemination of research‐based findings into community‐based practice.

The NIDA/SAMHSA Blending Initiative encompasses three

components:

• Regional Blending Conferences• State Agency Partnerships• Blending Teams

Regional Blending Conferences

• Enhance bi‐directional communication among:

• researchers, • practitioners, • and policy‐makers

• Share innovative scientific findings about drug abuse and addiction

• Convene in different regions of the country

State Agency Partnerships

• NIDA and SAMHSA work closely with federal and state policy‐makers to help identify strategies to accelerate the adoption of science‐based practices.

Blending Teams

• Use NIDA research findings to design user‐friendly science‐based tools for use in treatment settings soon after research results are published.

• Teams include members from: – SAMHSA‐CSAT Addiction Technology Transfer Center (ATTC) Network,

– NIDA researchers, and – Community treatment providers participating in the NIDA Drug Abuse Treatment Clinical Trials Network (CTN).

Blending Process

Selected CTN protocols or other NIDA

Research

Hand-Off MeetingCreate the charge for Blending Team

Blending Team Develop dissemination strategies and products

Current Blending Initiative Packages

Blending Initiative Packages Available in Spanish

BUPRENORPHINE/NALOXONE

A Focus on Medication‐Assisted Treatment

Buprenorphine and Buprenorphine/Naloxone Help Patients Quit Opiate Abuse Goal: to disseminate

information and enhance awareness among multi‐disciplinary addiction professionals about buprenorphine treatment

http://www.nida.nih.gov/NIDA_notes/NNvol19N3/Successful.html

Buprenorphine Treatment: A Training for Multidisciplinary

Addiction Professionals

Products in Package: – 6‐hour classroom training including a training manual, PowerPoint slides, and the short movie, “Put Your Smack Down! A Video About Buprenorphine”

– Annotated bibliography and research articles

Buprenorphine Treatment: A Training for Multidisciplinary

Addiction Professionals

Goal: to instruct treatment providers about the 13‐day buprenorphine intervention.

Short‐Term Opioid Withdrawal Using Buprenorphine

Product in Package:– 4‐hour classroom training program including PowerPoint slides and a CD

Buprenorphine/Naloxone

Buprenorphine

Results: Present and Opioid Negative 0001 (Inpatient)

0102030405060708090

Day 3-4 Day 7-8 Day 10-11 Day 13-14

Clonidine Bup/Nx

% of Ind

ividua

ls present at e

nd of tap

er

% of opioid free urines

0102030405060708090

Day 3-4 Day 7-8 Day 10-11 Day 13-14

Clonidine Bup/Nx

% of Ind

ividua

ls present at e

nd of tap

er

% of opioid free urines

Results: Present and Opioid Negative 0002 (Outpatient)

Goal: to present the results of a buprenorphine trial conducted with young adults.

Buprenorphine Treatment for Young Adults: Findings and Strategies from a NIDA Clinical Trials Network Study

Product in Package: 3‐hour classroom training program including PowerPoint slides and a CD

Results: Opioid Positive Urine Tests

OUTCOMES

Buprenorphine‐Related Blending Initiative Products

The ATTC Network has:

• Completed 764 Blending Product Trainings from January 2005‐September 2011 (with a total of 15,958 people)–134 Buprenorphine Treatment (3,317 people)–18 Short Term Opioid Withdrawal Using Buprenorphine (801 people)

–22 Buprenorphine for Young Adults (318 people)


• Printed and distributed 567,000 brochures introducing each of the Blending Initiatives materials to the field

• Recruited and prepared trainers in every ATTC Region to teach the Blending Initiative materials

• Developed and distributed ancillary products to enhance the reach of the official NIDA products, such as curriculum infusion packages for addiction studies educators at colleges and universities.


• Presented information on the Blending Initiative at State, Regional, and National conferences to:– Increase awareness about the training materials

– Identify new opportunities to train using the blending products

Products Currently Under Development

1. POATS (Prescription Opioid Addiction Treatment Study)**

2. Onsite HIV Rapid Testing Blending Initiative

Product Dissemination

Download the Products for FREE! Find upcoming trainings offered through SAMHSA’s ATTC Network!

Go to http://www.attcnetwork.org/blendinginitiative





Panel Agenda

MAT in Special Populations


Shawna Malvini Redden, MAArizona State UniversityPacific Southwest ATTC

[email protected]

Laurie Krom, MSUniversity of Missouri‐Kansas City

ATTC National [email protected]

Agenda

• Overview of the Project• Focus Group Findings• Products Developed• Next Steps

Overview of the Project

Purpose of the ProjectSAMHSA grant (TI‐10‐014) to increase awareness, provide education, and promote access to medication‐assisted treatment (MAT) in four specific racial and ethnic minority populations:

African Americans

Asian/Pacific Islanders

Hispanic/Latinos

Native Americans/American Indians

Overview of the Project

Purpose of the Project

Goals of the Grant:

1. Collect data and resources to inform the development of products

2. Develop outreach materials for each of the special populations

3. Create training programs for MAT providers designed to enhance professionals’ knowledge and skills related to reaching and educating the special populations about MAT

4. Plan for additional trainings and dissemination of materials

Overview of the ProjectStructure Utilized to Achieve Goals

Agenda


Focus Group Goals

• To understand the perceived benefits and barriers of MAT

• To identify attitudes, values and social norms surrounding substance use

• To learn how experiences and perspectives with MAT differ among various cultural groups

• To prepare the substance abuse treatment workforce to engage minority populations in MAT

Collaborators

• “Procedural Core” led by the Pacific Southwest ATTC with Arizona State University researchersOther ATTC Regional Centers in the “Procedural Core”

• Northwest Frontier ATTC at OHSU• Prairielands ATTC at U of Iowa• Central East ATTC at Danya Institute• Caribbean Basin & Hispanic ATTC at UCC

• ATTC Regional Centers conducted recruitment

• Culturally matched Facilitators/Ambassadors led meetings

• Fieldworker/Note‐taker assisted at all meetings

Study Design‐ Overview

• 8 qualitative focus groups, 90 minutes each

• Four minority populations– African American– American Indian– Asian American/Pacific Islander– Hispanic/Latino

• 10‐12 participants per group using MAT for 6 months

• Outpatient behavioral health clinics & substance abuse treatment centers

• New York, Los Angeles (2), Honolulu, Chicago, Oklahoma City (2), Seattle

Study Design

• Recruitment: – Flyers and handouts in clinics– $20 gift card incentives

• Procedures:– Focus group guide directed conversation– Information letters for participants– Client information sheets (demographics)– Pseudonyms chosen– Meetings were digitally recorded (audio only)– Refreshments provided– Incentives given after the meeting

Participants

• 68 participants– 15 African American – 18 Asian American – 19 Hispanic Latino – 16 Native American/

American Indian• Primarily unemployed• Mostly high school

educated0

2

4

6

8

10

12

14

Afr.Am.

AsianAm.

H/L NativeAm.

FemaleMaleTransgender

Participants

0

5

10

15

20

25

20s 30s 40s 50s 60s 70s 80s

Age Distribution of Participants

Participants

Data Analysis

• Focus groups professionally transcribed

• Codebook developed for analysis – Code Examples:

• Benefits• Ease of Access• Self‐Efficacy• Culture‐ Language• Family Support• Street Culture

• Fieldnotes & transcriptions coded by 3 researchers

Broad Themes

Benefits/Barriers related to MAT

Motivation to use MAT

Role of Family/Significant others

Access to treatment/Barriers

Self‐Efficacy

Influence of provider/clinic

MAT as drug v. MAT as medication

Surprising Results

! Weak emphasis on ethnic culture throughout most groups

! Strong emphasis on street/drug culture

! Definitions of “a good life”/motivations

! Family as a double‐edged sword

! Importance of “fictive kin” and clinic support

In Situ Particulars

• Participant lucidity– Dosing– “Nodding out”

• Children

• Ambient noise

• Room temperature

• Hostile participants

• Time constraints

• Late participants/Interruptions

Reflections/Recommendations

• Advantage of facilitator consistency v. facilitator specificity

• Broad v. local geographic sampling

• Saturation per cultural group

• Screening procedures (ethnicity v. culture)

Reflections/Recommendations

• Participant demographics (gender, age, type of substance)

• Remember discrepancies between research and practice– Reading level of participant materials– Un‐useful Incentives

• Importance of focus groups for emergent data

Agenda


Products

Outreach Materials• Brochures

• Pass‐along Cards

• Posters

• Website

2 Online Courses• SUD Tx Providers

• Primary Care Practitioners

Outreach Materials

Brochure – Side 1

Outreach Materials

Brochure – Side 2

Outreach Materials

Pass–along Card4 versions

Outreach Materials

Poster4 versions

Outreach Materials

Spanish versions

Online Courses

• 2 Self‐paced, online courseso SUD Tx Providers (NAADAC, NBCC, IC & RC, NASW

CEUs)o Primary Care Practitioners (CMEs)

• 7 modules, 2 hours each

• Narrated Presentations, Videos, Readings, Quizzes, Homework

Online Courses

• 3 Core Moduleso Module 1 – context, epidemiology, effects of alcohol

& opioidso Module 2 – meds for alcohol and opioid addiction,

introduction to findRXinformation.org, tx settings for MAT

o Module 3 – implementing MAT, recovery and MAT

• 4 Population‐specific Moduleso Module 4 – African Americanso Module 5 – Asian/Pacific Islandero Native American/American Indian Moduleo Hispanic/Latino Module

Website (in development)

Find everything here

Agenda


Next Steps – Data Directions

• Data used to inform development of recruitment/educational materials

• Data used to inform the development of a broad quantitative provider survey (in progress)

• Data currently being developed into two academic papers, one based upon focus group methodology, one focused on client identity and recovery

Next Steps – Product Dissemination

• Pilot test outreach materials (plan under development)

• Pilot test online courses (plan under development)

• Revise materials and courses as necessary

• Develop distribution plan for materials

• Develop marketing plan for courses

Panel Agenda• About the Addiction Technology Transfer Center (ATTC) Network• Setting the Context: Where are we with MAT?• NIDA/SAMHSA Blending Initiative Overview: A focus on

medication‐assisted treatment• MAT in Special Populations

Panel Questions?

Olivia [email protected]

Traci [email protected]

Thomas [email protected]

Beth [email protected]

Shawna Malvini Redden [email protected]

Laurie [email protected]

Closing the gap between research and practice: Successful technology transfer strategies in combating resistance to medication-assisted treatment

ATTC Network Efforts to Combat Resistance to MAT (2011 AHSR Conference)

Health & Medicine

Transcript of ATTC Network Efforts to Combat Resistance to MAT (2011 AHSR Conference)