A DOPTION OF E VIDENCE -B ASED P RACTICES IN THE CTN Paul M. Roman & Amanda J. Abraham University of Georgia Presentation at the NIDA Clinical Trials Network.

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A DOPTION OF E VIDENCE -B ASED P RACTICES IN THE CTN Paul M. Roman & Amanda J. Abraham University of Georgia Presentation at the NIDA Clinical Trials Network 10 th Anniversary Symposium, April 21, 2010 Albuquerque, New Mexico

UGA P LATFORM S TUDY OF CTN D EVELOPMENT AND I MPACT (2001- PRESENT ) Goal of this Presentation: To explore organization-level adoption, implementation, and discontinuation of evidence-based treatment practices (EBPs) Two types of data analysis Comparing the CTN to non-CTN programs Change within the CTN over time Adoption of: Buprenorphine Motivational incentives/contingency management Alcohol pharmacotherapies

M ETHODOLOGY Face-to-face interviews with administrators and/or clinical directors of CTPs & mail/internet based surveys with counselors in CTPs Three waves of data collection Baseline ( ) 24 month follow-up 48 month follow-up Comparisons with 2 nationally representative samples: Publicly funded programs (N=318) Privately funded programs (N=345)

D ISSEMINATION AND THE CTN Dissemination of the results of CTN trials is a major part of the CTN mandate This mandate has moved into prominence as the results of trials have been rolled out Research Utilization Committee has mobilized much energy and in collaboration with ATTCs CTN continues to develop and refine “Blending Products” and conduct “Blending Conferences”

D ISSEMINATION AND THE CTN (2) “Dissemination science” is complex and developed in the context of commercial marketing and at the level of groups and individuals weak at the organizational level What is the proper performance measure of “dissemination responsibility” of the CTN? To put information about new treatment options in front of organizational consumers? Moving innovations “all the way” to implementation?

D ISSEMINATION IN THE CTN (3) Implementation responsibility at the level of the individual provider Providers are a complex mix of public, non-profit and for-profit organizations, based in diverse settings Providers need strategic planning and a business orientation in using disseminated knowledge from the CTN in making implementation investments

A DOPTION OF B UPRENORPHINE : S UMMARY OF R ESEARCH F INDINGS 1. Study comparing adoption of buprenorphine in CTN and Non-CTN OTPs (Ducharme & Roman, 2009) CTN affiliation was significantly associated with buprenorphine adoption 2. Study examining adoption of buprenorphine over 2 year period in the CTN (Knudsen, Abraham, Johnson & Roman, 2009) Baseline adoption of buprenorphine was positively associated with continued use at 24m follow-up Buprenorphine protocol involvement was positively associated with adoption Much of buprenorphine adoption at 24m follow-up was in programs without protocol experience

L ATEST F INDINGS FROM THE P LATFORM S TUDY

ADOPTION OF BUPRENORPHINE OVER A 4 YEAR PERIOD IN THE CTN Roman, Abraham, Rothrauff, & Knudsen Journal of Substance Abuse Treatment, 38(4): S44-S52.

A DOPTION OF B UPRENORPHINE OVER 4 YEAR PERIOD IN THE CTN: C ROSS - SECTIONAL DATA

A DOPTION OF B UPRENORPHINE OVER 4 YEAR PERIOD IN THE CTN: L ONGITUDINAL DATA (N=129) 41%

B ARRIERS TO B UPRENORPHINE A DOPTION AMONG NON - ADOPTERS R OMAN, A BRAHAM, R OTHRAUFF, & K NUDSEN J OURNAL OF S UBSTANCE A BUSE T REATMENT, 38(4): S44-S52. OTPs (N=21) Cost associated with buprenorphine (23.8%) Lack of access to a waivered physician (19.0%) Non-OTPs, do not prescribe any medications (N=156) 38 programs did not have access to prescribing staff, so adoption was not possible Regulatory barriers (25.9%) Inconsistent with treatment philosophy, better alternatives available (18.5%) Liability issues (18.5%) Non-OTPs, prescribe other medications (N=40) Cost of buprenorphine (17.5%) Prescriber did not have a buprenorphine waiver (17.5%) Current medical personnel prefer not to prescribe buprenorphine (10%)

A DOPTION OF M OTIVATIONAL I NCENTIVES O VER 4 Y EAR P ERIOD IN THE CTN Roman, Abraham, Rothrauff, & Knudsen Journal of Substance Abuse Treatment, 38(4): S44-S52.

A DOPTION OF M OTIVATIONAL I NCENTIVES OVER 4 YEAR PERIOD IN THE CTN: C ROSS - SECTIONAL DATA

A DOPTION OF M OTIVATIONAL I NCENTIVES OVER 4 YEAR PERIOD IN THE CTN: L ONGITUDINAL DATA (N=124) 61%

B ARRIERS TO MI/CM ADOPTION AMONG NON - ADOPTERS R OMAN, A BRAHAM, R OTHRAUFF, & K NUDSEN J OURNAL OF S UBSTANCE A BUSE T REATMENT, 38(4): S44-S52. Cost associated with implementation (32.5%) Lack of compatibility with program’s philosophy(15.4%) Logistical issues such as competing demands, short length of stay, lack of a developed protocol for implementing MI/CM (11.4%) Perceived ineffectiveness of MI/CM with the program’s population (10.6%)

A DOPTION OF A LCOHOL P HARMACOTHERAPIES IN CTN AND N ON -CTN P ROGRAMS Abraham, Knudsen, Rothrauff, & Roman Journal of Substance Abuse Treatment, 38(3):

D ATA Pooled sample of publicly funded CTN and non-CTN programs 127 CTN programs 147 Non-CTN programs Utilized data collected at baseline ( ) and 24-month follow-up

A DOPTION OF TABLET NALTREXONE FOR ALCOHOL DEPENDENCE *Adoption of tablet naltrexone increased by 6.3% over time in the CTN and did not change in non-CTN programs.

E ARLY A DOPTION OF ACAMPROSATE

K EY F INDINGS A BRAHAM, K NUDSEN, R OTHRAUFF, & R OMAN J OURNAL OF S UBSTANCE A BUSE T REATMENT, 38(3): CTN participation was not a significant predictor of tablet naltrexone adoption at baseline At 24-month follow-up, CTN programs were three times more likely than non-CTN programs to adopt tablet naltrexone net of program structure and culture, environmental scanning, membership in a provider association, and administrator education CTN programs were three times more likely than non- CTN programs to adopt acamprosate in 2006 net of program culture, environmental scanning, membership in a provider association, and administrator education

S UMMARY OF PLATFORM STUDY F INDINGS Successful adoption of buprenorphine in the CTN Greater adoption of EBPs in CTN versus non-CTN treatment programs Overall importance of research network in promoting adoption of EBPs

A CKNOWLEDGEMENTS We gratefully acknowledge the research support of the National Institute on Drug Abuse (Grant No. R01DA14482, R21DA020028, and R01DA013110), and the participation of community treatment programs affiliated with the CTN in this research study.

A VAILABILITY OF PHYSICIANS 27% of CTN programs do not have a physician on staff/contract Of programs with physicians: 54% of non-OTP CTN programs with a physician on staff/contract do not prescribe alcohol pharmacotherapies 23% of CTN programs do not prescribe buprenorphine

A VAILABILITY OF PHYSICIANS : C OMPARISONS TO THE PUBLIC AND PRIVATE SECTOR 27% of CTN programs do not have a prescribing physician on staff/contract 23% of private programs do not have a prescribing physician on staff/contract 38% of public programs do not have a prescribing physician on staff/contract

P RESCRIPTION OF PHARMACOTHERAPIES : C OMPARISON TO THE PUBLIC AND PRIVATE SECTORS Of programs with a physician: 41% of private programs with access to a physician do not prescribe alcohol pharmacotherapies and 49% do not prescribe buprenorphine 82% of public programs with access to a physician do not prescribe alcohol pharmacotherapies and 67% do not prescribe buprenorphine 54% of non-OTP CTN programs with access to a physician do not prescribe alcohol pharmacotherapies and 23% of CTN programs do not prescribe buprenorphine