1. The CTN Research Utilization Committee: Putting Dissemination Research into Practice Jeffrey Selzer, MD Chair, CTN Research Utilization Committee Long Island Regional Node, CTN North Shore-Long Island Jewish Health System Albert Einstein College of Medicine

2. A research infrastructure of 16 RRTCs & 240 CTPs across 34 States, and Puerto Rico National Drug Abuse Treatment Clinical Trials Network

3. Missions of the CTN: A. Conduct studies of behavioral, pharmacological and integrated behavioral and pharmacological treatment interventions in rigorous, multi-site clinical trials to determine effectiveness across a broad range of community based treatment settings and diversified patient populations. B. Timely transfer of the research results to clinicians, providers, their patients and the policy makers to improve the quality of drug abuse treatment throughout the country using science as the vehicle. CTN strategic plan includes the importance of using the CTN as an infrastructure to study best approaches to disseminating treatment innovations.

4. Pending, Development & Review Recruitment & Data Collection CollectionFollow-UpFollow-Up Data Analysis, Publication, & Dissemination CTN 0027 CTN 0028 CTN 0029 CTN 0030 CTN 0027 CTN 0028 CTN 0029 CTN 0030 CTN 0014 CTN 0001 CTN 0002 CTN 0003 CTN 0004 CTN 0005 CTN 0006 CTN 0007 CTN 0008 CTN 0009 CTN 0010 CTN 0011 CTN 0012 CTN 0013 CTN 0015 CTN 0016 CTN 0017 CTN 0018 CTN 0019 CTN 0020 CTN 0021 CTN 0001 CTN 0002 CTN 0003 CTN 0004 CTN 0005 CTN 0006 CTN 0007 CTN 0008 CTN 0009 CTN 0010 CTN 0011 CTN 0012 CTN 0013 CTN 0015 CTN 0016 CTN 0017 CTN 0018 CTN 0019 CTN 0020 CTN 0021 CTN 0022 CTN 0023 CTN 0024 CTN 0025 CTN 0026 CTN 0031 CTN 0032 CTN 0022 CTN 0023 CTN 0024 CTN 0025 CTN 0026 CTN 0031 CTN 0032 The CTN Trials (1999 – now) Medical Interventions: 9 Behavior Interventions: 11 HIV/HCV Interventions: 4 Others: 3 Medical Interventions: 9 Behavior Interventions: 11 HIV/HCV Interventions: 4 Others: 3

5. “I utilize the best from Freud, the best from Jung, and the best from my Uncle Marty, a very smart fellow.”

6. Patient Outcomes Effective intervention practices + Effective implementation practices = Good outcomes for Patients

8. Characteristics of an Innovation Which Is Most Easily Disseminated (Everett Rogers, 2003): 1.Confers a relative advantage compared with the current practice 2.Is compatible with other current practices 3.Is relatively simple to learn and implement 4.May be tried before making a commitment to adoption 5.Positive results are observable by the adopter When innovations are adopted, “reinvention is inevitable.”

10. Widely Used Dissemination Approaches: 1. Conference presentations 2. Workshops 3. Distribution of printed manuals 4. Performance feedback which does not occur in real-time None of these commonly used approaches has been demonstrated to effectively promote dissemination of innovations.

11. Effective Strategy For Implementing a New Intervention Three-step process –Provide opportunities to acquire basic knowledge about intervention –Provide opportunities for practice with feedback –Provide expert coaching to improve performance Not dissimilar from how interventions in research protocols are implemented (i.e., training with fidelity monitoring)

12. Conclusions reached by the RUC: Implementation of interventions throughout the CTN would require ongoing technical assistance (i.e., coaching) For implementation to occur, “maintenance was as important sales.”

13. Initiative Blending Initiative SAMHSA-NIDA Collaboration through ATTCsSAMHSA-NIDA Collaboration through ATTCs BlendingTeam members include NIDA researchers on a given intervention, community treatment programs with experience using the intervention, and Addiction Technology Transfer Center staff Blending products (designed to promote adoption):Blending products (designed to promote adoption): → Buprenorphine Awareness → Short-Term Opioid Withdrawal Using Buprenorphine: Findings and strategies* → SMART Treatment Planning: Utilizing the ASI → MI Assessment: Supervisory Tools for Enhancing Proficiency* → Promoting Awareness of Motivational Incentives* *Based on CTN Studies

14. CTN Research Utilization Workgroups: Motivational Interviewing Buprenorphine Treatment Motivational Incentives (Selection of interventions based on CTP needs and by availability of Blending Products. Opportunity to “kick the tires” on the Blending Products.)

15. CTN Motivational Interviewing Trial Patients (n=423) assigned to MI at intake subsequently completed more counseling sessions (mean=5.02, sd=5.15) than Standard Care patients (mean=4.03, sd=4.21) during 28 days after randomization (p<.05) MI patients more likely (84%) to still be enrolled at the program after one month than Standard Care patients (75%) (p<.04)

16. Agreement about Occurrence

17. MIAMIA STEP Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency

18. MIA: STEP is… –A multi-media tool kit for enhancing MI proficiency in clinicians already knowledgeable about MI (“The last thing we need is another MI training manual.” Bill Miller) –A resource for supervisors to help them become more effective supervisors –A supervisory model which emphasizes fidelity to the intervention and bringing actual clinical material into supervision

19. 16 Rating Items MI Consistent MI Style or Spirit Open-ended Questions Affirmations Reflections Fostering Collaboration Motivation to Change Developing Discrepancies Pros, Cons, and Ambivalence Change Planning Discussion Client-centered Feedback MI Inconsistent Unsolicited Advice Emphasize Abstinence Direct Confrontation Powerlessness/Loss of Control Asserting Authority Closed-ended Questions

20. Motivational Interviewing Workgroup: Bill Miller (Researcher who developed MI) Steve Martino (Researcher in CTN MI study) Steve Gallon (ATTC Director) Chris Farentinos (CTP Representative)

21. Train-the-Trainer in Use of the Blending Product Applicants from CTN Nodes and ATTCs had to first demonstrate MI proficiency using the MITI system. 51 applicants + 3 MIA: STEP trainers 1/3 of the applicants were unable to demonstrate MI proficiency in the first round 26 passed from CTN/18 passed from ATTC by the second round Trained 42 individuals as MIA: STEP trainers

22. Training 2.5 days in Kansas City – sponsored by the ATTC National Office Product overview Step-by-step experiential walk-through of MIA: STEP Discussion of implementation issues

23. MIA: STEP Dissemination Model? MIA: STEP

24. Roll-outs completed Prince William County Community Services Board, Virginia N = 17 North Carolina Alcohol Drug Abuse Treatment Centers N = 39 –Included psychiatrists, medical doctors, nurses, recreational therapists, SA counselors, social workers at three sites Hawaii State Providers N = 25 ChangePoint, Oregon N = 5 Baltimore, Maryland N = 6

25. Roll-outs completed Miami-Dade County/South Florida Provider Coalition, 240 supervisors trained 100 hardcopies with CDs have been distributed; NFATTC and Mid-Atlantic ATTC both have 200 copies. http://www.motivationalinterview.org/lib rary/MIA-STEP.pdf is averaging 12,000 downloads per week!http://www.motivationalinterview.org/lib rary/MIA-STEP.pdf is averaging 12,000

26. Implementation Considerations MI training prerequisites Individual vs. group supervision Frequency Setting-specific modifications Agency support State support Curriculum/On-going consultations (CEUs) Support to train MIA: STEP

27. Where do we go from here? Listserv – Mid-Atlantic ATTC? Ongoing technical assistance for trainers, including more practice sessions/co-ratings? Quarterly conference calls open to trainers and supervisors? Obligations of trainers and $ to support them? Annual training of trainers or link training to Blending Conference MI Proficiency standards: MITI or MIA: STEP and with what support? Establish point person for ATTC (Gallon?) and CTN (Martino?) How to monitor effectiveness of strategy?

28. What is missing? 99% = Investment in Intervention Research to develop solutions 1% = Investment in Implementation Research to make effective use of those solutions (Up from ¼% in 1977)

29. Implementation Research Underway in the CTN 7 Nodes 12 Studies underway Interventions: Motivational Interviewing; CBT; TSF; Motivational Incentives; Process Improvement Strategies Implementation variables: role of fidelity measures; cultural adaptations; Web-based and interactive CD Rom-based training; factors promoting adoption after the end of CTN trials

30. Many thanks for your attention!