The NIDA/SAMHSA-ATTC Blending Initiative: New Tools for Bringing Research into Clinical Settings Beth Rutkowski, M.P.H., & Thomas Freese, Ph.D. UCLA Integrated Substance Abuse Programs/Pacific Southwest Addiction Technology Transfer Center

So who are the participants in this endeavor?

An Introduction to SAMHSA/CSAT

SAMHSA/CSAT To improve the lives of individuals and families affected by alcohol and drug abuse by ensuring access to clinically sound, cost-effective addiction treatment that reduces the health and social costs to our communities and the nation. CSAT's initiatives and programs are based on research findings and the general consensus of experts in the addiction field that, for most individuals, treatment and recovery work best in a community-based, coordinated system of comprehensive services. Because no single treatment approach is effective for all persons, CSAT supports the nation's effort to provide multiple treatment modalities, evaluate treatment effectiveness, and use evaluation results to enhance treatment and recovery approaches. CSAT’s Mission:

The ATTC Network

ATTC of New England Northeast ATTC Pacific Southwest ATTC Northwest Frontier ATTC Prairielands ATTC Mid-America ATTC Great Lakes ATTC Gulf Coast ATTC Mountain West ATTC Mid-Atlantic ATTC Southern Coast ATTC Southeast ATTC Central East ATTC Caribbean Basin, Hispanic/Latino & US Virgin Islands ATTC Central East ATTC Northwest Frontier ATTC ATTC National Office

An Introduction to NIDA

NIDA's mission is to lead the Nation in bringing the power of science to bear on drug abuse and addiction

So what is this thing called the CTN?

NIDA’s C linical T rials N etwork Established in 1999 NIDA’s largest initiative to blend research and clinical practice by bringing promising therapies to community treatment providers Network of 17 University-based Regional Research and Training Centers (RRTCs) involving 116 Community Treatment Programs (CTPs) in 24 states, Washington D.C., and Puerto Rico

CTN RRTC States with CTP CTN Nodes

Regional Research & Training Center Community Treatment Program Community Treatment Program Community Treatment Program Community Treatment Program Community Treatment Program CTN Node Community Treatment Program Community Treatment Program Community Treatment Program

Goals of the Agreement Take “what we know” from NIDA-funded research and produce products for use by addiction field: –Training materials –Pamphlets –Bibliographies/reading materials –On-line courses

Current Blending Teams Buprenorphine Awareness S.M.A.R.T. Treatment Planning Buprenorphine Detoxification Motivational Interviewing (MIA:STEP) Motivation Incentives (PAMI)

NIDA/SAMHSA-ATTC Initiative Blending Team Buprenorphine Treatment: A Training for Multidisciplinary Addiction Professionals

Buprenorphine Awareness Blending Team Members ATTC Members: Thomas Freese, Pacific Southwest ATTC, Chair Beth Finnerty, Pacific Southwest ATTC Glenda Clare, Central East ATTC Gail Dixon, Southern Coast ATTC NIDA Members: Leslie Amass, Friends Research Institute, Inc. Greg Brigham, CTN Ohio Valley Node Eric Strain, Johns Hopkins University

Goals for the Bup Awareness Blending Team Creation of a package of materials to increase the awareness of the usefulness of buprenorphine for treating opiate addiction among non-physician practitioners. To provide information designed to increase motivation for bringing buprenorphine to local communities as a treatment option To provide information relevant to non-physician providers about what to expect when someone is treated with buprenorphine.

Bup Awareness Blending Team Products Standup Training Package –5-6 hour awareness training –20-minute stand alone introduction CEATTC On-line Course –Self-paced option Additional Materials –Brochures –National Office Annotated Bibliography

Blending Team Products Standup Training Package – 6 modules –Module I: Introduction Myths about opiate addiction and treatment Changes in laws regarding opiate treatments Role of buprenorphine in treatment system Brief history of opiate treatment

Blending Team Products Standup Training Package – 6 modules –Module I: Introduction to Opioid Treatment What leads to opiate addiction History of opiate treatment Receptor pharmacology Use of agonists, partial agonists, and antagonists in treatment

Blending Team Products Standup Training Package – 6 modules –Module II/III: Buprenorphine/Opiate 101 Overview of the medication and how it works The role of buprenorphine in treatment –Induction –Maintenance –Medically-Assisted Withdrawal

Blending Team Products Standup Training Package – 6 modules –Module IV: Identification of Patients for Buprenorphine Treatment Where are opiate dependent patients seen? Screening and identification of opiate dependent individuals Ways for providers to facilitate treatment Understanding who is an optimal candidate for buprenorphine treatment

Blending Team Products Standup Training Package – 6 modules –Module V: Coordinated Care How to find a physician who can prescribe Bup Roles of providers Working within the scope of practices/using linkages to other providers No wrong door to treatment

Blending Team Products Standup Training Package – 6 modules –Module VI: Counseling Buprenorphine Patients Craving and Triggers Working with Special Populations Buprenorphine-Related Patient Management Issues

Key Components of this Package Available through the 14 regional ATTCs and 17 Nodes of the CTN. Designed to be completely customizable to meet the needs of each state. An important new resource for your states to assist in integrating this important new treatment in local treatment environments.

NIDA/SAMHSA-ATTC Initiative Blending Team S.M.A.R.T. Treatment Planning: Utilizing the Addiction Severity Index

S.M.A.R.T. Treatment Planning Blending Team Members ATTC Members: Richard Spence, Gulf Coast ATTC, Chair Nancy Roget, Mountain West ATTC Pat Stilen, Mid-America ATTC NIDA Members: Deni Carise, Treatment Research Institute Meghan Love, Treatment Research Institute A. Thomas McLellan, Treatment Research Institute

S.M.A.R.T Treatment Planning Utilizing the Addiction Severity Index S pecific M easurable A ttainable R ealistic T ime related

S.M.A.R.T. Treatment Planning Goal and Focus: –Transform required paperwork (e.g., ASI, psychosocial assessment) into clinically useful information –The focus of the training is on incorporating the assessment information in treatment planning and using the treatment plan to guide service delivery

S.M.A.R.T. Treatment Planning Information covered: –Addiction Severity Index (ASI) application in treatment planning –Individualized treatment plans vs. program- driven plans –Evaluation uses for program directors and clinical supervisors –Role of treatment plan in clinical records –Experiential writing exercises

Training manual including trainer notes and PowerPoint slides On-line training program Additional products –Quick guide –Lesson plans –Bibliography S.M.A.R.T Treatment Planning Utilizing the Addiction Severity Index

Module 1: Learn how the results from administering the ASI can make a counselor’s task easier and be able to discern differences between program-driven and individualized treatment plans Module 2: Identify and understand individualized treatment plans and how these plans can improve client retention/treatment outcomes Module 3: Practice formulating treatment plans using ASI information Module 4: Practice formulating documentation notes based on treatment plan progress. S.M.A.R.T Treatment Planning Course Content

NIDA/SAMHSA-ATTC Initiative Blending Team: Buprenorphine for Opioid Detoxification Based on Results from CTN Protocols for Inpatient Detox (CTN0001) and Outpatient Detox (CTN0002)

Buprenorphine Detox Blending Team Members ATTC Members: Thomas Freese, Pacific Southwest ATTC, Chair Beth Finnerty, Pacific Southwest ATTC Kay Gresham Morrison, Southeast ATTC Steven Gumbley, ATTC of New England NIDA Members: Greg Brigham, CTN Ohio Valley Node Judy Harrer, CTN Ohio Valley Node Dennis McCarty, CTN Oregon Node

Buprenorphine for Opioid Detoxification Goals: Training for physicians to conduct the 13- day buprenorphine taper evaluated through the CTN studies. Information for other multidisciplinary treatment personnel to support patients who are receiving this treatment

Buprenorphine Detox Blending Team Products Four hour classroom training program providing instruction on using buprenorphine for opioid dependent patients. Including: –Rational for providing detoxification to opioid dependent patients –Characterization of opiate withdrawal –Goals of detoxification –Results of the CTN studies –Implementation training –Patient and treatment staff perspectives –Overdose risk following detoxification

Present and Opioid Negative 0001 (Inpatient)

Present and Opioid Negative 0002 (Outpatient)

NNT: Number Needed to Treat NNT= Number of patients needed to treat to achieve 1 treatment success CTN 0001 (Inpatient) NNT for Bup/Nx 77/59 = 1.31 NNT for Clonidine 36/8 = 4.5 NNT Clonidine : BupNx = 3.44 CTN 0002 (Outpatient) NNT for Bup/Nx: 157/46 = 3.4 NNT for Clonidine: 74/4 = 18.5 NNT Clonidine : Bup/Nx = 5.44

Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP) NIDA/SAMHSA-ATTC Initiative Blending Team

Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP) Blending Team Members ATTC Members: Steven Gallon, Northwest Frontier ATTC, Chair Sherry Ceperich, Mid-Atlantic ATTC Maria del Mar Garcia, Caribbean Basin & Hispanic ATTC Denise Pyle, Mid-Atlantic ATTC Edna Quinones, Caribbean Basin & Hispanic ATTC NIDA Members: Samuel Ball, CTN New England Node John Hamilton, CTN New England Node Steve Martino, CTN New England Node

What is an MI Assessment? Use of client-centered MI style MI strategies that can be integrated into the agency’s existing intake assessment process Methods that can be used with diverse substance use problems Skills for assisting clients in assessing their own substance use Understanding the client’s perception and willingness to enter into a treatment process

Implementing MI may require: Focused clinical supervision Audio taped MI Assessment sessions Tape coding Feedback, coaching and instruction for improving skills

Benefits of MI Assessment It has a solid evidence-base MI improves client engagement and retention Using MIA:STEP:  Enhances clinical supervision  Builds counselor knowledge and proficiency in MI

Why another application of MI? Positive outcomes depend on clients staying in treatment for adequate length of time Adding MI at beginning of treatment increases client retention The type of clinical supervision needed to maintain and improve MI skills is generally lacking

The costs of implementing MI Assessment Time to learn and implement the protocol Regular review and feedback on MI skills Ongoing clinical supervision, including: - Training- Mentoring - Practice- Review of recorded interviews - Feedback- Development of learning plans The cost of recorders and supplies

Why consider this approach when staff are already trained in MI? Most trained clinicians do not use MI appropriately, effectively or consistently MI is more difficult than clinicians expect The key to successful implementation of MI is supervisory feedback and coaching

Development of the protocol The NIDA Drug Abuse Treatment Clinical Trials Network designed the protocol Designed as something that all outpatient community treatment providers could use Researchers worked directly with MI experts and treatment providers on both development and implementation.

MI Assessment “Sandwich” MI strategies during 1 st 20 min MI strategies during last 20 min MI strategies during last 20 min Agency Intake or Assessment

MIA:STEP Toolkit includes everything you need to: Introduce the idea of doing an MI assessment Train counselors and supervisors Provide ongoing supervision of MI Train supervisors to use a simple tape rating system Use an MI style of supervision

MIA:STEP Toolkit Overview 1.Briefing materials 2.Summary of the MI Assessment intervention 3.Results of the NIDA CTN Research 4.Teaching tools for enhancing and assessing MI skills 5.Tape rating guide and demonstration materials 6.Supervisor training curriculum

Promoting Awareness of Motivational Incentives (PAMI) NIDA/SAMHSA-ATTC Initiative Blending Team

Promoting Awareness of Motivational Incentives (PAMI) Blending Team Members ATTC Members: Lonnetta Albright, Great Lakes ATTC, Chair Joe Rosenfeld, Great Lakes ATTC Amy Shanahan, Northeast ATTC Anne Helene Skinstad, Prairielands ATTC NIDA Members: John Hamilton, CTN New England Node Scott Kellogg, CTN New York Node Therese Killeen, CTN South Carolina Node

Rationale for Developing the PAMI Blending Package Research has shown that motivational incentive programs using low-cost reinforcement (prizes, vouchers, clinic privileges, etc.), delivered in conjunction with onsite urine screening promotes higher rates of treatment retention and abstinence from drug abuse. This Blending Team is focusing its efforts on informing the field about successful approaches in the use of motivational incentives (also referred to as contingency management).

Motivational Incentives for Enhanced Drug Abuse Recovery Study Week Percentage Retained Improved Retention in Counseling Treatment 50% vs. 35% retained in the 12-week study using low-cost incentives.

Motivational Incentives for Enhanced Drug Abuse Recovery Week Percentage of negative samples Incentives Improve Outcomes in Methamphetamine Users 46% vs. 30% presented negative results when tested for Methamphetamines.

Motivational Incentives for Enhanced Drug Abuse Recovery Study Visit Percentage of stimulant negative samples Incentives Reduce Stimulant use in Methadone Maintenance Treatment 61% vs. 31% presented negative results when tested for stimulants.

Goals of the PAMI Blending Package Designed to acquaint the addiction treatment field with Motivational Incentives as a science- based therapeutic strategy. Elements incorporate examples of successful MI principles and strategies including the Fishbowl method. Illustrates positive outcomes and lessons learned from the NIDA Motivational Incentives Enhanced Drug Abuse Recovery (MEIDAR) CTN study.

PAMI Blending Team Products Blending Team products are currently being developed and will include a: Awareness video PowerPoint presentation Brochure Resource CD Tool Kit (supporting materials)

For more information Contact your Regional ATTC ATTC of New England Northeast ATTC Pacific Southwest ATTC Northwest Frontier ATTC Prairielands ATTC Mid-America ATTC Great Lakes ATTC Gulf Coast ATTC Mountain West ATTC Mid-Atlantic ATTC Southern Coast ATTC Southeast ATTC Central East ATTC Caribbean Basin, Hispanic/Latino & US Virgin Islands ATTC Central East ATTC Northwest Frontier ATTC ATTC National Office

More Information and Regional ATTC Web Pages Can Be Found at: ATTC National Office

The End For more information, please contact: Beth Rutkowski, M.P.H., (310) Thomas Freese, Ph.D., (310)