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TREATMENT CHARACTERISTICS & QUALITY: CHALLENGES AND EBTs
DOUGLAS NOVINS, M.D.UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS
NIDA Roundtable Meeting on Substance Use Disorders among American Indian/Alaska Natives in Urban Settings
Topics to Cover Challenges to Service Delivery
(Qualitative) EBT Knowledge (Qualitative) EBT Engagement (Quantitative) EBT Use (Quantitative) Attitudes Towards EBTs & Perceived
Cultural Appropriateness (Qualitative and Quantitative)
Challenges for Service Delivery Clinical challenges
poverty trauma histories
Infrastructure challenges not having enough staff staff feeling burned out
not having enough time or resources Service system challenges Not having enough housing Access to mental health treatment
Challenges for Service Delivery Clinical challenges
poverty trauma histories
Infrastructure challenges not having enough staff staff feeling burned out
not having enough time or resources Service system challenges not having enough housing Access to mental health treatment
“There are so many survival
needs that come first—
housing, a job, food, things like
outpatient treatment are
probably last on the list.”
“’I grew up in an alcoholic home, I was
raised in a foster home, I was in a
boarding school, I may have had sexual
abuse, I may have been physically
abused or emotionally abused . . . .’ That’s
what’s walking in your door. It’s not
simple….”
“…It’s not ‘I’m drinking a six-pack a day and I really get
drunk on the weekends. Help me sober up.’ [W]hat’s
coming to light for our communities is the
trauma that has happened for so many
generations to our communities and still is happening, so how
do we fix that?
“you have to have a certain amount of flexibility and
willingness to wade through the mud and muck of
peoples’ lives everyday because these people come in here when everything is falling apart.” Therefore,
“at the end of your day, you feel like you just don’t have anything left because . . .
it’s so intense.”
“[Clients] know if they go back to their homeland
there’s all the drinking and drug use going on [so they] relocate, [but] sometimes we have people staying three weeks to a month later waiting for housing
because the [lack of] availability and the
funding.”
“It’s all good and well to have evidence-based
treatment, but for who? Who does it work for? . . .
[Y]ou’ve got to realize that it’s different in each
community.”
Knowledge of EBTs Asked respondents in Phase 2 qualitative
interviews to define EBT. We analyzed their responses relative to Drake et. al.’s (2001) definition: “any practice that has been established as effective through scientific research…” Majority of respondents accuratly defined
evidence-based treatments. “effective” (80%) “research” (71%). Synonyms “empirical” (9%), “data” (9%), and “(it)
works” (28%).
“Pretty simply it’s the treatment techniques that have been researched and have proven to be effective in a population that’s been monitored.”
Knowledge of EBTs 19% were unable to define an EBT.
“You know, I've heard it, I've seen it on the covers of the book. But, no, [I don’t know what it means].”
Knowledge of EBTs More detailed aspects of EBT definitions
Manual – 6% Replication – 3% Hierarchy of evidence – 0%
“Then, someone's going to write a curriculum, manualize it, get it all nice and beautiful, and then, they're going to implement it and see if it works. And, if it works, then it'll be an evidence-based practice and maybe it'll be [listed in] NREPP…”
EBT Use
Psychosocial EBTs
not familiarnot
interested in
see pros and cons
planning on using
using but not
permanentpermanent
useused in
past% w
rating ≥ 4
mean Rating0 1 2 3 4 5 6
Psychosocial TreatmentsCognitive Behavioral Therapy 4.2 1.1 8.9 3.7 24.1 56.4 1.6 82.1 3.6Motivational Interviewing 11.1 2.6 10.5 9.0 19.5 45.7 1.6 66.8 3.2Relapse Prevention Therapy 17.0 3.2 6.4 4.8 14.9 52.6 1.1 68.6 3.0Twelve-Step Facilitation 24.1 7.0 10.7 4.3 9.1 41.6 3.2 53.9 2.6Matrix Model 25.8 10.6 19.1 7.4 12.2 18.5 6.4 37.1 2.2Contingency Mgmt 55.2 7.4 13.7 5.8 6.3 9.5 2.1 17.9 1.2Behavioral Couples Therapy 69.2 3.1 16.2 4.2 4.2 2.6 0.5 7.3 0.8Community Reinforcement & Family Training 76.9 5.8 4.2 7.9 2.6 2.1 0.5 5.2 0.6
Multisystemic Therapy 81.4 5.8 7.9 1.1 1.1 1.6 1.1 3.8 0.4
Novins et al. (in preparation) Use of Evidence-Based Treatments in Substance Abuse Treatment Programs Serving American Indian and Alaska Native Communities.
Psychopharmacologic EBTs
Raw Ratings
Not Familiar
Not intereste
d in
See pros and
cons
Planning on
using
Using but not
permanent
Permanent use
Used in past
Pct With
Ratings ≥ 4
Mean Rating0 1 2 3 4 5 6
Medication TreatmentsMeds for Comorbidity 37.8 4.2 11.1 3.7 7.4 35.3 0.5 43.2 2.1Meds for Relapse Prevention 26.5 14.8 24.9 5.8 9.5 16.4 2.1 28.0 1.9Meds for Withdrawal 32.6 25.3 15.8 2.6 6.8 15.3 1.6 23.7 1.6
Overall EBT Engagement% of treatment
ratings ≥ 4% of participants with at
least one treatment rating ≥ 4Mean Score SD of Scores
Psychological Treatments (with CBT) 1.95 0.69 38.04% 95.8% (184/192)
Psychological Treatments (without CBT) 1.74 0.72 32.49% 54.2% (103/190)
Medication Treatments 1.88 1.29 31.67% 92.2% (177/192)
Factors Associated with Greater EBT Engagement - PsychosocialVariable B SE PDirect, IHS638 compact, state block grant funding, or tribal funds 0.32 0.13 0.01
Percent of clinical staff that are certified addiction counselor (none versus 1-50%)
-0.41 0.19 0.04
Years of education for clinical staff 0.07 0.03 0.04Program requires clinical staff to use EBTs 0.23 0.11 0.05
EBTs are considered in strategic planning 0.32 0.11 0.01
EBPAS Openness Scale 0.22 0.07 0.002
Factors Associated with Greater EBT Engagement - PsychopharmacologicVariable B SE PServes adolescents 0.61 0.30 0.04Medicaid or Fee for Service Funding 0.61 0.24 0.01Percent of clinical staff that are in recovery (none versus 1-50%) -0.77 0.33 0.02
Years of education for clinical staff 0.22 0.08 0.01
EBT Implementation
RPT CBT MI 12SF MM0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Follow manual exactlyUse the parts thought most helpfulRewrote manual to make it more culturally appropriate or better fit with programDon't use manual but use key concepts
Attitudes Towards EBTs Phase 2 results:
Concerns about cultural appropriateness – 42% Western/Biomedical influence – 19% (negative)
External mandates – 26% Tension between individualized care and
manualized treatments – 16% Resource drain – 13%
“Evidence based just means that they have found a certain treatment approach or philosophy that helps with a certain population and it’s not true for all populations.”
Perceptions of Cultural Appropriateness of EBTs: Latent Classes
Class 1 (n=53) Class 2 (n=96) Class 3 (n=42)0%
10%20%30%40%50%60%70%80%90%
100%
NegativeNeutralPositive
CBT [CM, MM, BCT] (4/9)
28% 50% 22%
Perceptions of Cultural Appropriateness of EBTs: Latent Classes
Class 1 Class 2 Class 30%
10%20%30%40%50%60%70%80%90%
NegativeNeutralPositive
MI [RPT, CRFT, MST](4/9)
Perceptions of Cultural Appropriateness of EBTs: Latent Classes
Class 1 Class 2 Class 30%
10%
20%
30%
40%
50%
60%
70%
NegativeNeutralPositive
12-SF (1/9)
Discussion Challenges to Service Delivery
(Qualitative) EBT Knowledge (Qualitative) EBT Engagement EBT Use Attitudes Towards EBTs & Perceived
Cultural Appropriateness (Qualitative and Quantitative)