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

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This presentation will address efforts by the ATTC Network to decrease the gap between research and practice and to influence understanding of factors that enhance uptake of innovations. This …

This presentation will address efforts by the ATTC Network to decrease the gap between research and practice and to influence understanding of factors that enhance uptake of innovations. This presentation outlines how pairing research with innovative dissemination techniques can enhance the use of EBPs related to MAT. The presentation will provide an overview of the Buprenorphine Suite, a training product designed by the ATTC Network to provide the SUD treatment field with the tools to access and adopt NIDA treatment protocols. Additionally this presentation will identify research undertaken by the Network which identifies barriers to providing MAT to minority populations.

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  • 1. 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 2011 Olivia Ryan, M.P.A. University of Missouri – Kansas City ATTC National Office ryanom@umkc.edu
  • 2. • 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. 3 The ATTC Network 2007‐2012
  • 4. 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.
  • 5. SAMHSA’s Plan for 2011-14 SAMHSA’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
  • 6. 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 initiative September 2009-2010 *Health Information Technology *
  • 7. What is Technology Transfer? Southern Coast
  • 8. What is Technology Transfer? Copyright 2010 ATTC Network
  • 9. • 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
  • 10. Setting the Context: Where are we with MAT? Addiction Health Services Research Conference 2011 Traci Rieckmann, Ph.D. Oregon Health & Sciences University Northwest Frontier ATTC rieckman@ohsu.edu
  • 11. Setting the Context – Agenda  Background  MAT Implementation  ATTC MAT Resources
  • 12.  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
  • 13. 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 (Marchand et al., 2011).  MAT is cost effective & provides more health benefits than  providing treatment without medication (M. Connock et al.,  2007) BACKGROUND
  • 14.  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
  • 15. Approved Medications Medications for Alcohol Dependence  Naltrexone (ReVia®, Vivitrol®, Depade®)  Disulfiran (Antabuse®)  Acamprosate Calcium (Campral®)  Medications for Opioid Dependence  Methadone  Buprenorphine (Suboxone® and Subutex®)  Naltrexone BACKGROUND
  • 16.  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
  • 17. Setting the Context – Agenda  Background  MAT Implementation  ATTC MAT Resources
  • 18. MAT IMPLEMENTATION Comprehensive Tx Plan Psychosocial Treatments Medications 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
  • 19. MAT IMPLEMENTATION ATTC Network Definition of Implementation Incorporating 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).
  • 20. 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
  • 21. 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). MAT IMPLEMENTATION ‐ BARRIERS
  • 22. 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
  • 23. 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). MAT IMPLEMENTATION ‐ BARRIERS
  • 24. 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). MAT IMPLEMENTATION ‐ BARRIERS
  • 25. 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 MAT IMPLEMENTATION ‐ BARRIERS
  • 26. Overcoming Workforce Barriers  Influence from society and other providers  Specific training leads to greater acceptability  While 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 (Wallack et al., 2010). MAT IMPLEMENTATION ‐ BARRIERS
  • 27. Achieving MAT Implementation  Where 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
  • 28. 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
  • 29. Setting the Context – Agenda  Background  MAT Implementation  ATTC MAT Resources
  • 30. 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
  • 31. 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. 
  • 32. • 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
  • 33. NIDA/SAMHSA  Blending Initiative  Overview: A Focus on Medication‐ Assisted Treatment Addiction Health Services Research Conference 2011 Thomas E. Freese, Ph.D. University of California – Los Angeles Pacific Southwest ATTC tfreese@mednet.ucla.edu Beth Rutkowski, M.P.H. University of California – Los Angeles Pacific Southwest ATTC brutkowski@mednet.ucla.edu
  • 34. NIDA/SAMHSA  Blending Initiative According to Webster’s Dictionary  definition To Blend means:  a. combine into an integrated whole;  b. produce a harmonious effect  http://www.merriam‐webster.com/dictionary/blend
  • 35. 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. 
  • 36. The NIDA/SAMHSA Blending  Initiative encompasses three  components: • Regional Blending Conferences • State Agency Partnerships • Blending Teams
  • 37. 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
  • 38. 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.
  • 39. 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).
  • 40. Blending Process Selected CTN protocols or other NIDA Research Hand-Off Meeting Create the charge for Blending Team Blending Team Develop dissemination strategies and products
  • 41. Current Blending Initiative  Packages
  • 42. Blending Initiative Packages Available in Spanish
  • 43. BUPRENORPHINE/NALOXONE A Focus on Medication‐Assisted  Treatment
  • 44. 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
  • 45. 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
  • 46. 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
  • 47. Results: Present and Opioid  Negative 0001 (Inpatient) 0 10 20 30 40 50 60 70 80 90 Day 3-4 Day 7-8 Day 10-11 Day 13-14 Clonidine Bup/Nx % of Individuals present at end of taper % of opioid free urines
  • 48. 0 10 20 30 40 50 60 70 80 90 Day 3-4 Day 7-8 Day 10-11 Day 13-14 Clonidine Bup/Nx % of Individuals present at end of taper % of opioid free urines Results: Present and Opioid  Negative 0002 (Outpatient)
  • 49. 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
  • 50. Results: Opioid Positive  Urine Tests
  • 51. OUTCOMES Buprenorphine‐Related Blending  Initiative Products
  • 52. 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)
  • 53. The ATTC Network has: • 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.
  • 54. The ATTC Network has: • 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
  • 55. Products Currently  Under Development  1. POATS (Prescription Opioid Addiction  Treatment Study)** 2. Onsite HIV Rapid Testing Blending  Initiative 
  • 56. Product  Dissemination Download the Products for FREE! Find upcoming trainings offered  through SAMHSA’s ATTC Network! Go to http://www.attcnetwork.org/blendinginitiative
  • 57. • 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
  • 58. MAT in Special Populations Addiction Health Services Research Conference 2011 Shawna Malvini Redden, MA Arizona State University Pacific Southwest ATTC shawna.malvini@asu.edu Laurie Krom, MS University of Missouri‐Kansas City ATTC National Office kroml@umkc.edu 
  • 59. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
  • 60. Overview of the Project Purpose of the Project SAMHSA 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
  • 61. 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
  • 62. Overview of the Project Structure Utilized to Achieve Goals
  • 63. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
  • 64. 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
  • 65. Collaborators • “Procedural Core” led by the Pacific Southwest ATTC with  Arizona State University researchers Other 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
  • 66. 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
  • 67. 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
  • 68. Participants • 68 participants – 15 African American  – 18 Asian American  – 19 Hispanic Latino  – 16 Native American/ American Indian • Primarily unemployed • Mostly high school  educated 0 2 4 6 8 10 12 14 Afr. Am. Asian Am. H/L Native Am. Female Male Transgender
  • 69. Participants 0 5 10 15 20 25 20s 30s 40s 50s 60s 70s 80s Age Distribution of Participants Participants
  • 70. 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
  • 71. 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
  • 72. 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
  • 73. In Situ Particulars • Participant lucidity – Dosing – “Nodding out” • Children • Ambient noise • Room temperature • Hostile participants • Time constraints • Late participants/Interruptions
  • 74. Reflections/Recommendations • Advantage of facilitator consistency  v. facilitator specificity • Broad v. local geographic sampling • Saturation per cultural group • Screening procedures (ethnicity v.  culture)
  • 75. 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
  • 76. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
  • 77. Products Outreach Materials • Brochures • Pass‐along Cards • Posters • Website 2 Online Courses • SUD Tx Providers • Primary Care Practitioners
  • 78. Outreach Materials Brochure – Side 1
  • 79. Outreach Materials Brochure – Side 2
  • 80. Outreach Materials Pass–along Card 4 versions
  • 81. Outreach Materials Poster 4 versions
  • 82. Outreach Materials Spanish versions
  • 83. Online Courses • 2 Self‐paced, online courses o 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
  • 84. Online Courses • 3 Core Modules o Module 1 – context, epidemiology, effects of alcohol  & opioids o 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 Modules o Module 4 – African Americans o Module 5 – Asian/Pacific Islander o Native American/American Indian Module o Hispanic/Latino Module
  • 85. Website (in development) Find everything here
  • 86. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
  • 87. 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
  • 88. 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
  • 89. 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 Ryan ryanom@umkc.edu Traci Rieckmann rieckman@ohsu.edu Thomas Freese tfreese@mednet.ucla.edu Beth Rutkowski brutkowski@mednet.ucla.edu Shawna Malvini Redden shawna.malvini@asu.edu Laurie Krom kroml@umkc.edu Closing the gap between research and practice: Successful technology transfer strategies in combating resistance to medication-assisted treatment

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