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

Closing the gap between research and practice: Successful technology transfer strategies in combating resistance to medication‐assisted treatment Panel IntroductionAddiction Health Services Research Conference 2011 Olivia Ryan, M.P.A. University of Missouri – Kansas City ATTC National Office ryanom@umkc.edu

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

The ATTC Network 2007‐2012 3

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

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

Our Role in SAMHSA’s Plan ATTC Activities related to each initiative September 2009-2010• 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 * *Health Information Technology

What is Technology Transfer? Southern Coast

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

Setting the Context – Agenda Background MAT Implementation ATTC MAT Resources

BACKGROUND 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).

BACKGROUNDMAT 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)

BACKGROUNDUse & Effectiveness 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).

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

BACKGROUNDMAT Trials 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

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

MAT IMPLEMENTATIONATTC 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).

MAT IMPLEMENTATION ‐ BARRIERSBarriers 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 ‐ BARRIERSBarriers 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 BARRIERS 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).

MAT IMPLEMENTATION ‐ BARRIERSOrganizational 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 ‐ BARRIERSOvercoming 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 ‐ BARRIERSWorkforce 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 ‐ BARRIERSOvercoming 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 ‐ SUCCESS 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 ‐ SUCCESSWhat 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).

ATTC NETWORK RESOURCESATTC Strategies to Accelerate the Use of MAT 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.

NIDA/SAMHSA Blending Initiative Overview: A Focus on Medication‐ Assisted TreatmentAddiction Health Services Research Conference 2011Thomas E. Freese, Ph.D.University of California – Los AngelesPacific Southwest ATTCtfreese@mednet.ucla.eduBeth Rutkowski, M.P.H.University of California – Los AngelesPacific Southwest ATTCbrutkowski@mednet.ucla.edu

NIDA/SAMHSA Blending InitiativeAccording to Webster’s Dictionary definitionTo Blend means: 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 ProcessSelected CTN protocols or other NIDA Research Hand-Off Meeting Create the charge for Blending Team Blending Team Develop dissemination strategies and products

Current Blending Initiative Packages

Blending Initiative Packages Available in Spanish

A Focus on Medication‐Assisted TreatmentBUPRENORPHINE/NALOXONE

Buprenorphine Treatment: A Training for Multidisciplinary Addiction Professionals Buprenorphine and Buprenorphine/Naloxone Help Patients Quit Opiate Abuse Goal: to disseminate information and enhance awareness among multi‐ disciplinary addiction professionals about buprenorphine treatmenthttp://www.nida.nih.gov/NIDA_notes/NNvol19N3/Successful.html

Buprenorphine Treatment: A Training for Multidisciplinary Addiction ProfessionalsProducts 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

Short‐Term Opioid Withdrawal Using BuprenorphineGoal: to instruct treatment providers about the 13‐day buprenorphine intervention. Buprenorphine/NaloxoneProduct in Package: – 4‐hour classroom training program including PowerPoint slides and a CD Buprenorphine

Results: Present and Opioid Negative 0001 (Inpatient) Clonidine Bup/Nx% of Individuals present at end of taper 90 80 70 60 50 40 30 20 10 0 Day 3-4 Day 7-8 Day 10-11 Day 13-14 % of opioid free urines

Results: Present and Opioid Negative 0002 (Outpatient) Clonidine Bup/Nx% of Individuals present at end of taper 90 80 70 60 50 40 30 20 10 0 Day 3-4 Day 7-8 Day 10-11 Day 13-14 % of opioid free urines

Buprenorphine Treatment for Young Adults: Findings and Strategies from a NIDA Clinical Trials Network StudyGoal: to present the results of a buprenorphine trial conducted with young adults. Product in Package: 3‐hour classroom training program including PowerPoint slides and a CD

Results: Opioid Positive Urine Tests

Buprenorphine‐Related Blending Initiative ProductsOUTCOMES

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)

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.

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

Products Currently Under Development 1. POATS (Prescription Opioid Addiction Treatment Study)**2. Onsite HIV Rapid Testing Blending Initiative

Product DisseminationDownload the Products for FREE! Find upcoming trainings offered through SAMHSA’s ATTC Network! Go to http://www.attcnetwork.org/blendinginitiative

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

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

Overview of the ProjectPurpose 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 Hispanic/Latinos Asian/Pacific Native Americans/ Islanders American Indians

Overview of the ProjectPurpose 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

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 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

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 14 – 15 African American 12 – 18 Asian American 10 – 19 Hispanic Latino 8 – 16 Native American/ Female 6 Male American Indian 4 Transgender• Primarily unemployed 2• Mostly high school 0 educated Afr. Asian H/L Native Am. Am. Am.

Participants Age Distribution of Participants25201510 Participants50 20s 30s 40s 50s 60s 70s 80s

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 ThemesBenefits/Barriers related to MATMotivation to use MATRole of Family/Significant othersAccess to treatment/BarriersSelf‐EfficacyInfluence of provider/clinicMAT 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

ProductsOutreach 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 Card 4 versions

Outreach Materials Poster4 versions

Outreach MaterialsSpanishversions

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

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

Website (in development)Find everything here

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 Questions?Closing the gap between research and practice:Successful technology transfer strategies in combatingresistance to medication-assisted treatmentPanel 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 PopulationsOlivia Ryan Thomas Freese Shawna Malvini Reddenryanom@umkc.edu tfreese@mednet.ucla.edu shawna.malvini@asu.eduTraci Rieckmann Beth Rutkowski Laurie Kromrieckman@ohsu.edu brutkowski@mednet.ucla.edu kroml@umkc.edu

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

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