1. Integrated Substance Abuse Programs Bridges have been built: Is anyone using them? Richard A. Rawson, Ph.D, Professor Supported 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

9. NIDA Clinical Trials Network (CTN)  Mission The 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.

10. 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.  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.

11. 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

12. 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.

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

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

15. Pacific Region Protocol Involvement  PROTOCOL0018 Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment PROTOCOL0018 Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment 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 PROTOCOL0019 Reducing HIV/STD Risk Behaviors: A Research Study for Women 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 PROTOCOL0027 Starting Treatment with Agonist Replacement Therapies – START PROTOCOL0027 Starting Treatment with Agonist Replacement Therapies – START  PROTOCOL0030 Prescription Opioid Addiction Treatment Study (POATS) PROTOCOL0030 Prescription Opioid Addiction Treatment Study (POATS) PROTOCOL0030 Prescription Opioid Addiction Treatment Study (POATS)

16. 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

17. 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

18. Running the Trials is not enough  Diffusion of Innovations. 4 th Edition  Everett M. Rogers - 1995 - New York: Free Press

19. Research Questions  NIDA’s CTN offers an important opportunity to examine if and how inter-organizational relationships promote innovation adoption Focus on buprenorphine and voucher-based motivational incentives 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? 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? Is “exposure” a predictor of adoption?

20. 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

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

22. 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.

24. 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.  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

25. The NIDA Methamphetamine Clinical Trials Group (MCTG)

26. 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

27. 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

28. 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

29. San Diego, CA South Bay Treatment Center Joseph Mawhinney, PI Division of Treatment Research & Development19 September 2000 Methamphetamine Clinical Trials Group (MCTG) Costa Mesa, CA Friends Research Institute Michael McCann, PI Des Moines, IA Powell Chemical Dependency Center Dennis Weis, PI Kansas City, MO University of Missouri, Kansas City Services, Inc. Jan Campbell, PI Honolulu, HI John A. Burns School of Medicine & Queens Hospital William Haning, PI Los Angeles, CA UCLA Coordinating Center Richard Rawson, PI

30. MCTG Studies  Behavioral Platform Study (Completed Oct, 2002). (N=60)  Ondansetron Study ( Completed Dec 1, 2003. (N=120  Bupropion Study (Completed June 1, 2005) (N=120)  Topirimate Study (Underway, projected completion, April 1, 2007 (N=120)  Modafinal Study (Projected to begin April 2007)

31. 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

32. Process Improvement 101 Reduce Waiting & No-Shows  Increase Admissions & Continuation

33. Why Process Improvement?  Customers are served by processes  85% of customer related problems are caused by organizational processes  To better serve customers, organizations must improve processes

34. 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) (37 agencies reporting) Reduce No-Shows: 41% reduction (28 agencies reporting) (28 agencies reporting) Increase Admissions: 56% increase (23 agencies reporting) (23 agencies reporting) Increase Continuation: 39% increase (39 agencies reporting) (39 agencies reporting)

36. 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

37.  Most important of all the Principles  What is it like to be a customer? Staff are customers, too!  Walk-through, focus groups… Understand and Involve the Customer

38. 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?

39. Detour 1 Unclear purpose!  Where are you going?  How will you know you have arrived?

40. Aim Statement  Example Improve 30-day continuation rates from 30% to 80% in outpatient services. Improve 30-day continuation rates from 30% to 80% in outpatient services.  Need Target Target Scope of work Scope of work

41. Detour 2 No feedback!  Need a tracking measure.  Have a simple measure.

42. California’s Proposition 36:Did it Work?

43. The Problem: California Prison Population, Drug Offenses, 1980-2000 Source: California Department of Corrections.

44. Increase in California Prison Population, Drug Offenses, 1970-1999 Rate per 100,000 Population Source: California Department of Corrections.

45. Solutions?

46. Proposition 36 Substance 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 supervision without treatment

47. 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.

48. Result 6,199,992 / 60.8% Yes votes 3,991,153 / 39.2% No votes 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)

49. Arrest or Parole Violation Treatment Conviction and Court Order of Probation and Treatment; or Parole Referral Treatment Completion Conviction Dismissed (probation) Assess ment No shows No shows Repeated violation and dropouts Ineligible No petition, petition denied Attrition Pipeline

50. Implementation Show Rates ReferredAssessedPlacedShow rate (%) Year 1 7/01-6/02 44,04337,49530,46969.2 Year 2 7/02-6/03 50,33542,97235,94771.4 Year 3 7/03-6/04 51,03342,88037,10372.6 Total145,411123,347103,51971.1

51. Client Characteristics Half use methamphetamines Half used primary drug more than 10 years Half are in treatment for first time

52. 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-offending New Arrests One 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 <.0001.

55. Any Drug Use in the Past 30 Days Group differences are statistically significant. a p<.05, b p<.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

57. What about costs?

58. 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.

59. 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 2.5:1. For treatment completers, the cost savings reflect a benefit-to-cost ratio of about 4:1

60. 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

64. 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 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

67. 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

69. 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

70. 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.

71. 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.

72. 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

73. 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

74. THANK YOU RRAWSON@MEDNET.UCLA.EDU WWW.UCLAISAP.ORG