1. The University of Georgia Trends in Adoption of Medications for Alcohol Dependence Lori J. Ducharme, J. Aaron Johnson, Hannah K. Knudsen & Paul M. Roman University of Georgia www.uga.edu/ntcs Supported by NIAAA Grant R01DA10130 and NIDA Grants R01DA13110 and R01DA14487

2. The University of Georgia Medications in Alcohol Treatment Substantial attention paid to the “research-to- practice gap” in addiction treatment Several medications are available or in the pipeline for alcoholism treatment What are the factors that predict adoption and use of medications by addiction treatment programs? What are the implications for diffusion of these treatment technologies?

3. The University of Georgia Diffusion of Innovations Innovations = new to the adopter Rogers (1995) suggests several factors central to innovation diffusion: –Compatibility – “fit” with org structure, resources, practices, and philosophy –Trialability – can “test” the technology without full commitment up front –Observability – can readily see results –Relative Advantage – better than what’s otherwise available –Complexity – can be learned easily; can be integrated without wholesale restructuring Diffusion is a process, but often measured as a discrete event

4. The University of Georgia Objectives Describe trends in adoption of disulfiram and naltrexone in the private sector, 1994-2004 –SSRIs shown as point of reference for same period Describe current patterns of use of these medications in public vs private sectors, 2004 Identify predictors of medication use, and barriers to adoption Examine counselor attitudes & receptivity Suggest implications for recently-approved medications (acamprosate)

5. The University of Georgia Data Sources 1.Panel data on N=252 private-sector addiction treatment facilities, 1994- 2004 2.Cross-sectional data on N=403 private- sector and N=362 public-sector treatment facilities, 2004 3.Cross-sectional data on N=2,200 counselors in these programs, 2004

6. The University of Georgia Private Sector Data, 1994-2004 Any Use of Medication in Program 199520002004 Disulfiram51.6%50.4%35.7% Naltrexone49.2%45.2%41.7% SSRIs77.0%73.4%68.3%

7. The University of Georgia Patterns of Adoption are Unstable Over Time DisulfiramNaltrexoneSSRIs Adopted + kept 32.1%35.7%59.1% Tried + dropped 37.7%30.6%26.2% Never tried26.6%27.8%5.6% Inconsistent3.6%6.0%9.1%

8. The University of Georgia Predictors of Adoption Greater reliance on private insurance and self-paying clients increased likelihood of using naltrexone or disulfiram at some point No clear predictors of “keepers” SSRIs as “gateway drug” – programs that don’t adopt SSRIs are unlikely to adopt other medications

9. The University of Georgia Panel data suggest overall low (and declining) adoption and implementation in the private sector. How does the public sector differ? Why should funding source matter? –Private insurance may be more likely to reimburse for medications, which represent a cost efficient technology. –We differentiate nonprofit sector by primary revenue source (majority public funds vs majority private funds) Integrating Data from the Public Sector

10. The University of Georgia Adoption, by Sector, 2004 % programs reporting any use of medication

11. The University of Georgia Implementation Rates % alcohol clients receiving meds, 2004 % primary alcohol patients receiving med All centers in sample For Profit Private NP Public NP Gov’t owned Disulfiram11.210.610.911.812.1 Naltrexone8.812.18.76.66.7 SSRIs58.062.961.748.854.9 Note: “public” and “private” refer to principal revenue sources, not ownership

12. The University of Georgia Adoption: Organizational Correlates (bivariate tests) Org structure: Hospital based (+) Inpatient only (-) Dual diagnosis enhanced (+) % Master’s level counselors (+) Physicians on staff (+) External stakeholders: Accredited (+) % public revenues (-) Legal system referrals (-) Org philosophy: % recovering staff (-) Admin has medical background (+) Patient characteristics: % primary alcohol (+) Total admissions (+)

13. The University of Georgia Adoption Predictors (multivariate logistic regressions) Disulfiram: physicians (+), hospital (+), public funded nonprofits (-), dual dx enhanced (+) Naltrexone: privately funded (+), accredited (+), dual dx enhanced (+), physicians (+), % masters counselors (+) SSRIs: physicians (+), public nonprofits (-), accredited (+), dual dx enhanced (+), % relapsers (+), legal system referrals (-), % masters counselors (+)

14. The University of Georgia Barriers to Adoption Administrators were asked, To what extent are these factors reasons for not using [medication]? (Shown: Percent responding “very much” / “extremely”) DisulfiramNaltrexone Inconsistent w/ tx philosophy53%39.5% Better alternatives available40.7%22% No medical personnel37%37.5% Staff resistance17.6%11.5% Cost / reimbursement issues9.8%12.1%

15. The University of Georgia A Look at Staff Attitudes Surveys of Counseling Staff, 2004 “Don’t Know” Effectiveness Acceptability Score (1-7) Disulfiram19.4%3.70 Naltrexone39.7%4.18 SSRIs31.9%4.81 For reference: 17% DK methadone, 61.6% DK buprenorphine, 85.9% DK acamprosate Perceptions increased with: extent of use at program; educational level; tenure in addiction treatment field

16. The University of Georgia Conclusions / Implications Use of disulfiram and naltrexone are low, and declining over time –Use is significantly higher among programs relying on private insurance & self-pays Medications appear to fail on “compatibility” factors –Program philosophy is a significant barrier –Medical staff availability is key –However, SSRIs are more widely used (more complete medicalization of psychiatric conditions?) Awareness of acamprosate is extremely low; adoption bears monitoring over time –How does program/staff experience with other meds affect willingness to use acamprosate?