Bridges have been built: Is anyone using them?

1
Bridges have been built Is anyone using
them?Richard A. Rawson, Ph.D,
ProfessorSupported by National Institute on
Drug Abuse (NIDA) Pacific Southwest
Technology Transfer Center (SAMHSA) United
Nations Office of Drugs and Crime
2
The Problem in 1996

• The US Substance Abuse Research and Treatment
  Systems each spend billions of dollars per year
  on the problem of substance abuse treatment.
• However, the efforts have traditionally been
  completely disconnected. Despite over 30 years
  of research findings, most treatment services are
  based on practices developed during the 1950s and
  1960s.

3
U.S. Agencies Involved with Substance Abuse
Research and Treatment
Research Agencies
NIH National Institutes of Health
NIDA National Institute on Drug Abuse
NIAAA National Institute on Alcohol Abuse
Alcoholism
4
U.S. Agencies Involved with Substance Abuse
Research and Treatment
Service Agencies
SAMHSA Substance Abuse, Mental Health Services
Administration
CSAT Center for Substance Abuse Treatment
CSAP Center for Substance Abuse Prevention
5
Traditional Culture of U.S. Substance Abuse
RESEARCH System

• University-based, academic personnel
• Minimal community involvement
• Treatment viewed condescendingly
• Publish data in professional journals
• Little systematic attempt to transfer knowledge
• Topics of research omit clinical concerns

6
Traditional Culture of U.S. Substance Abuse
SERVICE Delivery System

• Recovering/paraprofessional staff
• Minimal connections with academic tradition
• Personal ideology determines treatment choices
• Generally anti-medication
• Uneven and inadequate treatment funding
• Little attention to data
• Science viewed as irrelevant

7
Bridging the Gap A Benchmark

• Institute of Medicine (1998). S. Lamb, M.R.
  Greenlick, D. McCarty, D. (Eds.), Bridging the
  gap between practice and research Forging
  partnerships with community-based drug and
  alcohol treatment. Washington, DC National
  Academy Press.

8
THE NATIONAL INSTITIUTE ON DRUG ABUSE (NIDA)
CLINICAL TRIALS NETWORK (CTN)www.nida.nih.gov/CTN
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NIDA Clinical Trials Network (CTN)

• MissionThe mission of the Clinical Trials
  Network (CTN) is to improve the quality of drug
  abuse treatment throughout the country using
  science as the vehicle.The CTN provides an
  enterprise in which the National Institute on
  Drug Abuse, treatment researchers, and
  community-based service providers cooperatively
  develop, validate, refine, and deliver new
  treatment options to patients in community-level
  clinical practice. This unique partnership
  between community treatment providers and
  academic research leaders aims to achieve the
  following objectives
• Conducting studies of behavioral,
  pharmacological, and integrated behavioral and
  pharmacological treatment interventions of
  therapeutic effect in rigorous, multi-site
  clinical trials to determine effectiveness across
  a broad range of community-based treatment
  settings and diversified patient populations and
  
• Ensuring the transfer of research results to
  physicians, clinicians, providers, and patients.

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The NIDA CTN What is it?

• Network Organization
• The CTN framework consists of seventeen Nodes
  (Regional Research and Training Centers, linked
  with five to ten or more Community-based
  Treatment programs), a Clinical Coordinating
  Center, and a Data and Statistical Center. 
• This allows the CTN to provide a broad and
  powerful infrastructure for rapid, multi-site
  testing of promising science-based therapies and
  the subsequent delivery of these treatments to
  patients in community-based treatment settings
  across the country.

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The Pacific Node of the CTN

• The Pacific Region Node is a partnership between
  the Regents of the University of California, Los
  Angeles and several community treatment programs
  in the State.
• The Pacific Node incorporates researchers and
  clinicians from throughout California. Many of
  the clinical networks have been involved in the
  transfer of research into practice for over a
  decade

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NIDA CTN How does it work?

• Research concepts are generated at each of the
  Nodes after discussion between researchers and
  clinicians.
• These concepts are proposed to the CTN group and
  are voted on. Those receiving highest vote go to
  director of NIDA for approval.

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Pacific Region Protocol Involvement

• PROTOCOL0001 Buprenorphine/Naloxone for Opiate
  Detoxification - INpatient
• PROTOCOL0002 Buprenorphine/Naloxone for Opiate
  Detoxification - OUTpatient
• PROTOCOL0004 Motivational Enhancement Treatment
  (MET)
• PROTOCOL0006 Motivational Incentives - Drug Free
  Clinics
• PROTOCOL0007 Motivational Incentives - Methadone
  Clinics
• PROTOCOL0008 A Baseline for Investigating
  Diffusion of Innovation

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Pacific Region Protocol Involvement

• PROTOCOL0009 Smoking Cessation Treatment With
  Transdermal Nicotine Replacement Therapy In
  Substance Abuse Rehabilitation Programs
• PROTOCOL0012 Characteristics of Screening,
  Evaluation, and Treatment of HIV/AIDS, Hepatitis
  C Viral Infection, and Sexually Transmitted
  Infections in Substance Abuse Treatment Programs
• PROTOCOL0014 Brief Strategic Family Therapy
  (BSFT) For Adolescent Drug Abusers

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Pacific Region Protocol Involvement

• PROTOCOL0018 Reducing HIV/STD Risk Behaviors A
  Research Study for Men in Drug Abuse Treatment
• PROTOCOL0019 Reducing HIV/STD Risk Behaviors A
  Research Study for Women in Drug Abuse Treatment
• PROTOCOL0027 Starting Treatment with Agonist
  Replacement Therapies START
• PROTOCOL0030 Prescription Opioid Addiction
  Treatment Study (POATS)

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CTN Strengths

• Has provided a true forum for researchers and
  clinicians to interact cooperatively and
  collaboratively
• Has generated a significant amount of new
  published research
• Research and surrounding publications do appear
  to be promoting some transfer of research to
  practice in CTN-affiliated treatment
  organizations
• Annual Blending Conference and Journal

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CTN Limitations (opinion)

• Extremely expensive
• Extremely bureaucratic and committee heavy
• Productivity not commensurate with budget
• Bi-directionality of effort is only moderately
  successful (mostly researcher driven)
• Impact on the larger US treatment system is
  unknown

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Running the Trials is not enough

• Diffusion of Innovations. 4th Edition
• Everett M. Rogers - 1995 - New York Free Press

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Research Questions

• NIDAs CTN offers an important opportunity to
  examine if and how inter-organizational
  relationships promote innovation adoption
• Focus on buprenorphine and voucher-based
  motivational incentives
• Are CTPs in the CTN protocols significantly more
  likely to adopt bup and/or vouchers?
• Is trialability a predictor of adoption?
• Does membership in the CTN confer advantages to
  CTPs that are not involved in these protocols?
• Is exposure a predictor of adoption?

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Adoption of Buprenorphine

• CTPs that participated in the buprenorphine
  trials were significantly more likely to have
  adopted buprenorphine than CTPs not in the trials
  and non-CTN centers

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Logistic Regression Model of Buprenorphine
Adoption

• Controlling for other organizational factors
• CTPs in the buprenorphine protocols were 5.2
  times more likely to use buprenorphine (at the
  6-month follow-up) than non-CTN programs (plt.01)
• Other significant predictors, net of effects of
  CTN exposure
• Center offers detox services (O.R. 3.59)
• Center has a physician on staff or contract (O.R.
  3.94)
• The percentage of primary opiate clients (O.R.
  1.009)

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Adoption of Voucher-Based Motivational Incentives

• These differences in adoption were not
  statistically significant

23
Discussion

• The ability to compare CTN vs. non-CTN centers
  provides a unique opportunity to examine a
  variety of factors that influence innovative
  behavior and the adoption of evidence-based
  practices at the organizational level.
• The longitudinal design of these studies will
  allow for observation of continued trends in
  adoption of these techniques.
• Future research is planned to examine the use of
  MET and motivational interviewing in CTN and
  non-CTN samples.

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From a clinical trial to technology transfer

• S. Kellogg, M. Burns, P. Coleman, M. Stitzer, J.
  Wale, M. Jeanne Kreek, M.D.
• Something of value The introduction of
  contingency management interventions into the New
  York City Health and Hospital Addiction Treatment
  Service. 
• Journal of Substance Abuse Treatment, 2005,
  Volume 28, Issue 1, Pages 57-65

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The NIDA Methamphetamine Clinical Trials Group
(MCTG)
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MCTG The Problem

• NIDA has a desire to speed up the development of
  medications for the treatment of methamphetamine
  use disorders.
• Too few research groups available in areas of the
  US with extensive methamphetamine use.
• As complexity of medication testing and
  regulatory system becomes more complex it is
  difficult for new investigators to initiate
  research

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MCTG The Solution

• Establish a training/coordinating center to
  train, organize and monitor sites.
• Establish a set of medication testing sites in
  regions with extensive methamphetamine use and an
  MD and team that can conduct trials.
• Decide on a medication(s) and protocol for study
• Initiate studies

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Methamphetamine Clinical Trials Group

• UCLA is the coordinating center for clinical
  studies
• 5 Sites participate on a contractual basis
• Primary focus-reduction of methamphetamine use
• All trials use a behavioral platform for all
  treated subjects

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Methamphetamine Clinical Trials Group (MCTG)
Los Angeles, CA UCLA Coordinating Center Richard
Rawson, PI
Division of Treatment Research
Development 19 September 2000
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MCTG Studies

• Behavioral Platform Study (Completed Oct, 2002).
  (N60)
• Ondansetron Study ( Completed Dec 1, 2003. (N120
• Bupropion Study (Completed June 1, 2005) (N120)
• Topirimate Study (Underway, projected completion,
  April 1, 2007 (N120)
• Modafinal Study (Projected to begin April 2007)

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MCTG Accomplishments

• Transferred state-of-the-art clinical trials
  methods to clinical sites with no previous
  research experience.
• Successful conducted 3 studies to date with one
  (bupropion) showing significant promise
• Sites now are capable of applying for independent
  research funding

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Process Improvement 101

Reduce Waiting  No-Shows ? Increase Admissions 
Continuation
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Why Process Improvement?

• Customers are served by processes
• 85 of customer related problems arecaused by
  organizational processes
• To better serve customers, organizationsmust
  improve processes

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NIATx Four Project Aims

• Reduce Waiting Times
• Reduce No-Shows
• Increase Admissions
• Increase Continuation Rates

35
NIATx Results

• Reduce Waiting Times 51 reduction
• (37 agencies reporting)
• Reduce No-Shows 41 reduction
• (28 agencies reporting)
• Increase Admissions 56 increase
  
• (23 agencies reporting)
• Increase Continuation 39 increase
• (39 agencies reporting)

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Five Key Principles Evidence-based predictors of
change

• Understand Involve the Customer
• Focus on Key Problems
• Select the Right Change Agent
• Seek Ideas from Outside the Field and
  Organization
• Do Rapid-Cycle Testing

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Understand and Involve the Customer

• Most important of all the Principles
• What is it like to be a customer? Staff are
  customers, too!
• Walk-through, focus groups

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Focus on Key Problems

• What is keeping the executive director awake at
  night?
• What processes have staff and customers
  identified as barriers to excellent service?

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Detour 1

• Unclear purpose!
• Where are you going?
• How will you know you have arrived?

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Aim Statement

• Example
• Improve 30-day continuation rates from 30 to 80
  in outpatient services.
• Need
• Target
• Scope of work

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Detour 2

• No feedback!
• Need a tracking measure.
• Have a simple measure.

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Californias Proposition 36Did it Work?
43
The ProblemCalifornia Prison Population, Drug
Offenses, 1980-2000
Source California Department of Corrections.
44
Increase in California Prison Population, Drug
Offenses, 1970-1999Rate per 100,000 Population
Source California Department of Corrections.
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Solutions?
46
Proposition 36Substance Abuse Crime Prevention
Act (SACPA)

• 2000 Ballot Measure Passed by 61 of California
  voters in 2000
• Authorized 600,000,000 in new funds for
  implementation. 2001-2006.
• Drug offenses Non-sales, non-manufacturing.
• Restrictions on offenders with histories of
  serious or violent crimes
• Results in community supervision and treatment
  instead of Incarceration or
• supervision without treatment

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2000 Proposition 36 Ballot Wording

• Proposition 36. Drugs. Probation and Treatment
  Program. Requires probation and drug treatment,
  not incarceration, for possession, use,
  transportation of controlled substances and
  similar parole violations, except sale or
  manufacture. Authorizes dismissal of charges
  after completion of treatment.

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Result

• 6,199,992 / 60.8 Yes votes 3,991,153 /
  39.2 No votes
• Proposition 36 passed and was enacted as the
• Substance Abuse Crime Prevention Act
• (SACPA)

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Pipeline
Arrest or Parole Violation
Conviction and Court Order of Probation and
Treatment or Parole Referral
Assessment
Conviction Dismissed
Treatment Completion
Treatment
(probation)
Repeated
No
No
No

violation and
petition,
Ineligible
shows
shows
petition
dropouts
denied
Attrition
50
ImplementationShow Rates
Referred Assessed Placed Show rate ()
Year 1 7/01-6/02 44,043 37,495 30,469 69.2
Year 2 7/02-6/03 50,335 42,972 35,947 71.4
Year 3 7/03-6/04 51,033 42,880 37,103 72.6
Total 145,411 123,347 103,519 71.1
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Client Characteristics

• Half use methamphetamines
• Half used primary drug more than 10 years
• Half are in treatment for first time

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Treatment Summary

• 34 of clients who enter treatment complete it
• Most clients are sent to outpatient treatment
• Heroin users rarely get methadone treatment
• Heroin users are least likely to complete

53
Re-offendingNew ArrestsOne Year After Offense,
Year 1 (7/01 - 6/02) Population
54
Any Work in the Past 30 Days
a,b Group differences are statistically
significant, p .04. Pre-post differences (not
shown) are all statistically significant, p
lt.0001.
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Any Drug Use in the Past 30 Days
Group differences are statistically significant.
aplt.05, bplt.02.
56
Outcome Summary Effect of SACPA As Policy

• SACPA-era offenders have more drug arrests in the
  initial 12 months
• Initial re-offending is affected by differences
  in incarceration rates
• Violent re-offending is low in all groups

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What about costs?
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SUMMARY OF FINDINGS
Notes Figure provides a summary of cost
offsets. The zero-line can be interpreted as
cost neutral. Any bar above the line represents
a cost increase and any bar below the line
represents a cost saving.
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COSTS UNDER SACPA

• Savings primarily from prison, jail reductions.
• Cost increases primarily from increased
  treatment, new crimes.
• Costs are 2,861 per offender lower than what
  we would expect in the absence of SACPA.
• Benefit-to-cost ratio of about 2.51.
• For treatment completers, the cost savings
  reflect a benefit-to-cost ratio of about 41

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KEY COST ANALYSIS FINDINGS

• Substantially reduced incarceration costs.
• Greater cost savings for some offenders than for
  others
• Can be improved

61
California Prison Population, Drug Offenses,
1980-2000
Source California Department of Corrections.
62
California Prison Population, Drug Offenses,
1980-2004
Source California Department of Corrections.
63
Conclusion

• 70 of referrals have entered treatment
• Methamphetamine is the most common drug
• Half are in treatment for the first time
• 34 of clients have completed treatment
• Initial re-offending is lowest for completers
• Employment is highest for completers
• Abstinence is highest for completers, but overall
  drug use outcomes are uneven

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Prop 26 (SACPA) Is it good policy?

• Approximately 200,000 individuals will have
  received treatment over program
• Final report currently in process
• Fiscal impact appears quite positive
• No group has come out to revoke SACPA
• Disagreements concern exact provisions
• Failure to pass revised SACPA provisions could
  result in funding responsibility being passed on
  to counties.

65
UNODC International Network of Treatment and
Rehabilitation Resource Centres
66
Recognizing and Addressing the Need to Expand
Training and Treatment Capacity to Address
Substance Abuse Problems

• There is a need for trained professionals to
  deliver effective rehabilitation and harm
  reduction interventions for substance abuse and
  dependence around the world
• The paucity of properly trained professional is a
  barrier to the development and delivery of
  effective treatment services, especially
  regarding underserved and inappropriately served
  populations of drug abusers, including women and
  children
• There is a worldwide shortage of qualified
  training experts and educational settings in
  which drug abuse treatment training is provided,
  particularly in developing regions
•  
• A goal of this training effort is to train
  clinicians and educate academics who will train
  additional professionals to address the problems
  of drug abuse in an empirically rational method

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Capacity Building Plan

• In short, the goal of the capacity building plan
  is to increase the number of personnel who can
  disseminate and promote the use of effective,
  scientifically-supported and practical drug abuse
  treatment practices around the world.

68
Treatnet Members

• RS Ketergantungan Obat The Drug Dependence
  Hospital, Indonesia
• Iranian National Prison Organisation /Iranian
  National Centre for Addiction Studies INCAS, Iran
  
• National Research and Clinical Centre on Medical
  and Social Problems of Drug, Kazakhstan
• Drug Rehabilitation Unit, Mathari Hospital, Kenya
  
• Centros de Integración Juvenil A.C., Mexico
• Neuropsychiatric Hospital Aro, Nigeria

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Treatnet Members

• Shanghai Drug Abuse Treatment Centre, China
• Carisma Centre for Attention and Integral Mental
  Health, Colombia
• General Secretariat of Mental Health, Egypt
• TT Ranganathan Clinical Research Foundation,
  India
• Regional Research Centre of Narcology and
  Psychopharmacology affiliated to St. Petersburg
  Pavlov State Medical University, Russia
• Psychosocial Attention Centre for Alcohol and
  other Drugs, Brazil

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Treatnet Members

• Turning Point Alcohol and Drug Centre Inc.,
  Australia
• Centre for Addiction and Mental Health CAMH,
  Canada
• Mudra, Germany
• Asociación Proyecto Hombre, Spain
• Maria Ungdom, Sweden
• Cranstoun Drug Services, United Kingdom
• Fayette Companies, U.S.A.
• Stanley Street Treatment Resources (SSTAR)
  Inc., U.S.A.

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Capacity Building Plan for UNODC Treatnet
Program What are we trying to do?

• The purpose of the capacity building component
  for the UNODC Treatnet Program is to develop a
  set of training materials and a training plan for
  trainers from 20 Resource Centres established by
  UNODC. To accomplish this task, we will
• 1. Conduct a training needs assessment.
• 2. Determine priority training/skill
  development topics.
• 3. Create a set of training modules to address
  2.
• 4. Conduct a set of training, supervision and
  mentoring activities with two trainers from each
  of the resource centres.
• 5. Collect information to contribute to the
  project evaluation.

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Need Assessment A Brief Summary

• The following topics received the most interest.
• Motivational Interviewing
• Relapse Prevention (CBT)
• Assessment
• Program management
• Outreach strategies
• Youth
• Building Service Networks
• Family
• Co-occurring
• Drugs and the brain
• Brief interventions
• Outpatient treatments
• Harm minimization
• Basic knowledge of drugs
• Research and evaluation methods

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Summary

• The issue of research practice integration has
  been a priority in the US for almost a decade.
• Major initiatives have been established to cross
  the research-practice gap.
• Clinicians are more aware of research value and
  findings
• Quality research can be done in clinical service
  delivery settings
• It continues to be a challenging, expensive, time
  consuming process

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THANK YOU

• RRAWSON_at_MEDNET.UCLA.EDU
• WWW.UCLAISAP.ORG