ATTC Network Efforts to Combat Resistance to MAT (2011 AHSR Conference)
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This presentation will address efforts by the ATTC Network to decrease the gap between research and practice and to influence understanding of factors that enhance uptake of innovations. This presentation outlines how pairing research with innovative dissemination techniques can enhance the use of EBPs related to MAT. The presentation will provide an overview of the Buprenorphine Suite, a training product designed by the ATTC Network to provide the SUD treatment field with the tools to access and adopt NIDA treatment protocols. Additionally this presentation will identify research undertaken by the Network which identifies barriers to providing MAT to minority populations.
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ATTC Network Efforts to Combat Resistance to MAT (2011 AHSR Conference)
- 2. • About the Addiction Technology Transfer Center (ATTC) Network • Setting the Context: Where are we with MAT? • NIDA/SAMHSA Blending Initiative Overview: A focus on medication‐ assisted treatment • MAT in Special Populations Panel Agenda
- 5. The ATTC Network’s Vision Southern Coast All professionals who address the needs of individuals with, or who are at risk of having, substance use disorders will utilize effective, culturally responsive practices that lead to improved healthcare and long-term health and wellness.
- 7. SAMHSA’s Plan for 2011-14 SAMHSA’s 8 Strategic Initiatives 1) Prevention of Substance Abuse and Mental Illness 2) Trauma and Justice 3) Military Families 4) Recovery Support 5) Health Reform 6) Health Information Technology 7) Data, Outcomes, and Quality 8) Public Awareness and Support
- 8. Our Role in SAMHSA’s Plan • The ATTC Network conducts numerous efforts across SAMHSA’s eight Strategic Initiatives • The ATTC Network is a stable infrastructure to address the objectives outlined by SAMHSA in the “Leading Change” plan ATTC Activities related to each initiative September 2009-2010 *Health Information Technology *
- 10. What is Technology Transfer? Copyright 2010 ATTC Network
- 11. • About the Addiction Technology Transfer Center (ATTC) Network • Setting the Context: Where are we with MAT? • NIDA/SAMHSA Blending Initiative Overview: A focus on medication‐ assisted treatment • MAT in Special Populations Panel Agenda
- 12. Setting the Context: Where are we with MAT? Addiction Health Services Research Conference 2011 Traci Rieckmann, Ph.D. Oregon Health & Sciences University Northwest Frontier ATTC rieckman@ohsu.edu
- 13. Setting the Context – Agenda Background MAT Implementation ATTC MAT Resources
- 14. Definition: MAT is the use of medication, combined with counseling and behavioral therapies, to provide a whole patient approach to the treatment of substance use disorders. (http://www.dpt.samhsa.gov ) Use of pharmacotherapy for drug dependence and detoxification is expanding Research continues to confirm that the use of MAT provides better outcomes, and reductions in drug use, mortality rates, and criminal activity (Rieckmann et al., 2010; Woody et al., 2008; Saxon & McCarty, 2005; Greenfeld & Fountain, 2000). BACKGROUND
- 15. MAT Effectiveness Published by SASMHA as Treatment Improvement Protocol (TIP) 43, MAT is a widely recognized evidence based practice Research indicates that MAT is effective for opioid dependent patients seeking treatment along with counseling (Marchand et al., 2011). MAT is cost effective & provides more health benefits than providing treatment without medication (M. Connock et al., 2007) BACKGROUND
- 16. Agonist therapy or MAT, has been hailed as the most effective treatment, especially when combined with psychotherapy (Barnett et al., 2001). MAT Goals: • Reduce symptoms and signs of withdrawal • Reduce or eliminate craving • Block effects of alcohol or illicit opioids • Restore normal physiology • Promote psychosocial rehabilitation and non‐drug lifestyle Research to date confirms lower risk of abuse, overdose, and toxicity and diminished withdrawal symptoms when using medication assisted treatment (Burns et al., 2009). BACKGROUND Use & Effectiveness
- 17. Approved Medications Medications for Alcohol Dependence Naltrexone (ReVia®, Vivitrol®, Depade®) Disulfiran (Antabuse®) Acamprosate Calcium (Campral®) Medications for Opioid Dependence Methadone Buprenorphine (Suboxone® and Subutex®) Naltrexone BACKGROUND
- 18. Clinical trials have demonstrated efficacy of MATs for opioid dependent patients • Clinical trial of Buprenorphine (Bickel et al., 1988) • CTN 0003: Suboxone taper: a comparison of two schedules (Amass et al., 2004; Ling et al., 2010). Physician Clinical Support System (Fiellin et al., 2008). • PCSS‐B BACKGROUND MAT Trials
- 19. Setting the Context – Agenda Background MAT Implementation ATTC MAT Resources
- 22. Barriers to Implementation Gap between research and practice • Adoption of medication to treat SUDs remains slow despite evidence of effectiveness • There is a critical need to merge the gap between research and practice with MAT Organizational factors • Two‐thirds of organizations' efforts to implement change fail (Damschroder et al., 2009). • Implementation requires an active change process aimed to achieve individual and organizational level use of the intervention as designed (Damshroder at al., 2009). MAT IMPLEMENTATION ‐ BARRIERS
- 24. Gap Between Research and Practice According to SAMHSA’s National Survey of Substance Abuse Treatment Services, only 22.3% of patients seeking treatment for a SUD were receiving medication assisted treatment‐ Methadone and Buprenorphine (Substance Abuse and Mental Health Services Administration, N‐SSATS Report, 2008). Similarly – The National Treatment Center Studies from UGA found that 14.3% of programs reported using Buprenorphine,10.7% use Methadone, 15.2% use Naltrexone, and 16.5% use Disulfiram, from a 2007 study (Knudsen et al., 2010). BARRIERSMAT IMPLEMENTATION ‐ BARRIERS
- 25. Organizational Factors as Barriers Agencies with national accreditation (Ducharme et al., 2008; Knudsen et al., 2010). Agencies that adhere to a 12‐step model Focus on individual, not organizational ‐ Much of the research on implementation of evidence‐based SUD interventions emphasizes individual counselor training, with less attention on the influence of organizational factors (Damschroder et al., 2011). MAT IMPLEMENTATION ‐ BARRIERS
- 26. Overcoming Organizational Barriers Characteristics of the medication and societal attitudes influence the adoption of medication assisted treatment (Knudsen et al., 2007; Mark et al., 2009; Ducharme et al., 2009; Rieckmann et al., 2011). State regulations may create or remove barriers to the adoption of MATs by community‐based treatment provider organizations (Ducharme et al., 2008). Persons endorsing a 12‐step model perceived less interest in addiction medication (McGovern et al., 2004). MAT IMPLEMENTATION ‐ BARRIERS
- 27. Workforce Barriers Environmental pressures including market and regulations, treatment philosophy, resource constraints, service objectives, and patient mix influence MAT adoption (Wallack et al., 2010; Scott et al., 1993). Lack of knowledge from physicians about medication assisted treatment (Mark et al., 2003). Complexity of treatment, costs, regulatory limits Differing physician beliefs: not enough evidence Need for physician training MAT IMPLEMENTATION ‐ BARRIERS
- 28. Overcoming Workforce Barriers Influence from society and other providers Specific training leads to greater acceptability While physician knowledge of effectiveness and an organization’s positive attitude toward medications are important, physicians are dependent on structural and procedural supports in their office settings to allow for MATs (Wallack et al., 2010). MAT IMPLEMENTATION ‐ BARRIERS
- 29. Achieving MAT Implementation Where to start: Listening and education • Do staff understand the need or gap in services? • Do staff understand the clinical implications of the change on their work? • Will clients be different from the ones we treat now? • Does staff have the requisite knowledge, tools, and equipment to be successful? MAT IMPLEMENTATION ‐ SUCCESS
- 30. What is Needed for Successful MAT Implementation Research indicates that training improves staff attitudes and beliefs (Johnson et al., 2005; Knudsen et al., 2005; Rieckmann et al., 2011). Research also suggests that experience with medications (for counselors) leads to more positive perspectives (Thomas et al., 2003; Knudsen et al., 2005). Research network participation helps promote positive attitudes toward EBPs (Campbell et al., 2003; Levant et al., 2008). MAT IMPLEMENTATION ‐ SUCCESS
- 31. Setting the Context – Agenda Background MAT Implementation ATTC MAT Resources
- 32. ATTC Strategies to Accelerate the Use of MAT ATTC NETWORK RESOURCES Examples of Product Development Strategies • Curricula • Marketing/Outreach Materials Examples of Educational Strategies • Online Courses, Regional Presentations & Trainings • Learning Collaboratives Examples of Organizational Change Strategies • Process Improvement • Coaching Examples of Systems Transformation Efforts • Collaborations with state officials to address varying state requirements, regulations and funding
- 34. • About the Addiction Technology Transfer Center (ATTC) Network • Setting the Context: Where are we with MAT? • NIDA/SAMHSA Blending Initiative Overview: A focus on medication‐ assisted treatment • MAT in Special Populations Panel Agenda
- 37. What is the Blending Initiative? • GOAL: To move important scientific findings into mainstream addiction treatment • Developed in 2001, NIDA and SAMHSA’s Center for Substance Abuse Treatment came together to work on a common vision: – Improve substance use disorder treatment and accelerate the dissemination of research‐based findings into community‐based practice.
- 38. The NIDA/SAMHSA Blending Initiative encompasses three components: • Regional Blending Conferences • State Agency Partnerships • Blending Teams
- 39. Regional Blending Conferences • Enhance bi‐directional communication among: • researchers, • practitioners, • and policy‐makers • Share innovative scientific findings about drug abuse and addiction • Convene in different regions of the country
- 41. Blending Teams • Use NIDA research findings to design user‐ friendly science‐based tools for use in treatment settings soon after research results are published. • Teams include members from: – SAMHSA‐CSAT Addiction Technology Transfer Center (ATTC) Network, – NIDA researchers, and – Community treatment providers participating in the NIDA Drug Abuse Treatment Clinical Trials Network (CTN).
- 42. Blending Process Selected CTN protocols or other NIDA Research Hand-Off Meeting Create the charge for Blending Team Blending Team Develop dissemination strategies and products
- 44. Blending Initiative Packages Available in Spanish
- 49. Results: Present and Opioid Negative 0001 (Inpatient) 0 10 20 30 40 50 60 70 80 90 Day 3-4 Day 7-8 Day 10-11 Day 13-14 Clonidine Bup/Nx % of Individuals present at end of taper % of opioid free urines
- 50. 0 10 20 30 40 50 60 70 80 90 Day 3-4 Day 7-8 Day 10-11 Day 13-14 Clonidine Bup/Nx % of Individuals present at end of taper % of opioid free urines Results: Present and Opioid Negative 0002 (Outpatient)
- 55. The ATTC Network has: • Printed and distributed 567,000 brochures introducing each of the Blending Initiatives materials to the field • Recruited and prepared trainers in every ATTC Region to teach the Blending Initiative materials • Developed and distributed ancillary products to enhance the reach of the official NIDA products, such as curriculum infusion packages for addiction studies educators at colleges and universities.
- 59. • About the Addiction Technology Transfer Center (ATTC) Network • Setting the Context: Where are we with MAT? • NIDA/SAMHSA Blending Initiative Overview: A focus on medication‐ assisted treatment • MAT in Special Populations Panel Agenda
- 61. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
- 63. Overview of the Project Purpose of the Project Goals of the Grant: 1. Collect data and resources to inform the development of products 2. Develop outreach materials for each of the special populations 3. Create training programs for MAT providers designed to enhance professionals’ knowledge and skills related to reaching and educating the special populations about MAT 4. Plan for additional trainings and dissemination of materials
- 65. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
- 66. Focus Group Goals • To understand the perceived benefits and barriers of MAT • To identify attitudes, values and social norms surrounding substance use • To learn how experiences and perspectives with MAT differ among various cultural groups • To prepare the substance abuse treatment workforce to engage minority populations in MAT
- 67. Collaborators • “Procedural Core” led by the Pacific Southwest ATTC with Arizona State University researchers Other ATTC Regional Centers in the “Procedural Core” • Northwest Frontier ATTC at OHSU • Prairielands ATTC at U of Iowa • Central East ATTC at Danya Institute • Caribbean Basin & Hispanic ATTC at UCC • ATTC Regional Centers conducted recruitment • Culturally matched Facilitators/Ambassadors led meetings • Fieldworker/Note‐taker assisted at all meetings
- 68. Study Design‐ Overview • 8 qualitative focus groups, 90 minutes each • Four minority populations – African American – American Indian – Asian American/Pacific Islander – Hispanic/Latino • 10‐12 participants per group using MAT for 6 months • Outpatient behavioral health clinics & substance abuse treatment centers • New York, Los Angeles (2), Honolulu, Chicago, Oklahoma City (2), Seattle
- 69. Study Design • Recruitment: – Flyers and handouts in clinics – $20 gift card incentives • Procedures: – Focus group guide directed conversation – Information letters for participants – Client information sheets (demographics) – Pseudonyms chosen – Meetings were digitally recorded (audio only) – Refreshments provided – Incentives given after the meeting
- 70. Participants • 68 participants – 15 African American – 18 Asian American – 19 Hispanic Latino – 16 Native American/ American Indian • Primarily unemployed • Mostly high school educated 0 2 4 6 8 10 12 14 Afr. Am. Asian Am. H/L Native Am. Female Male Transgender
- 71. Participants 0 5 10 15 20 25 20s 30s 40s 50s 60s 70s 80s Age Distribution of Participants Participants
- 72. Data Analysis • Focus groups professionally transcribed • Codebook developed for analysis – Code Examples: • Benefits • Ease of Access • Self‐Efficacy • Culture‐ Language • Family Support • Street Culture • Fieldnotes & transcriptions coded by 3 researchers
- 74. Surprising Results ! Weak emphasis on ethnic culture throughout most groups ! Strong emphasis on street/drug culture ! Definitions of “a good life”/motivations ! Family as a double‐edged sword ! Importance of “fictive kin” and clinic support
- 75. In Situ Particulars • Participant lucidity – Dosing – “Nodding out” • Children • Ambient noise • Room temperature • Hostile participants • Time constraints • Late participants/Interruptions
- 76. Reflections/Recommendations • Advantage of facilitator consistency v. facilitator specificity • Broad v. local geographic sampling • Saturation per cultural group • Screening procedures (ethnicity v. culture)
- 77. Reflections/Recommendations • Participant demographics (gender, age, type of substance) • Remember discrepancies between research and practice – Reading level of participant materials – Un‐useful Incentives • Importance of focus groups for emergent data
- 78. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
- 79. Products Outreach Materials • Brochures • Pass‐along Cards • Posters • Website 2 Online Courses • SUD Tx Providers • Primary Care Practitioners
- 85. Online Courses • 2 Self‐paced, online courses o SUD Tx Providers (NAADAC, NBCC, IC & RC, NASW CEUs) o Primary Care Practitioners (CMEs) • 7 modules, 2 hours each • Narrated Presentations, Videos, Readings, Quizzes, Homework
- 86. Online Courses • 3 Core Modules o Module 1 – context, epidemiology, effects of alcohol & opioids o Module 2 – meds for alcohol and opioid addiction, introduction to findRXinformation.org, tx settings for MAT o Module 3 – implementing MAT, recovery and MAT • 4 Population‐specific Modules o Module 4 – African Americans o Module 5 – Asian/Pacific Islander o Native American/American Indian Module o Hispanic/Latino Module
- 88. Agenda • Overview of the Project • Focus Group Findings • Products Developed • Next Steps
- 89. Next Steps – Data Directions • Data used to inform development of recruitment/educational materials • Data used to inform the development of a broad quantitative provider survey (in progress) • Data currently being developed into two academic papers, one based upon focus group methodology, one focused on client identity and recovery
- 90. Next Steps – Product Dissemination • Pilot test outreach materials (plan under development) • Pilot test online courses (plan under development) • Revise materials and courses as necessary • Develop distribution plan for materials • Develop marketing plan for courses
- 91. Panel Agenda • About the Addiction Technology Transfer Center (ATTC) Network • Setting the Context: Where are we with MAT? • NIDA/SAMHSA Blending Initiative Overview: A focus on medication‐assisted treatment • MAT in Special Populations Panel Questions? Olivia Ryan ryanom@umkc.edu Traci Rieckmann rieckman@ohsu.edu Thomas Freese tfreese@mednet.ucla.edu Beth Rutkowski brutkowski@mednet.ucla.edu Shawna Malvini Redden shawna.malvini@asu.edu Laurie Krom kroml@umkc.edu Closing the gap between research and practice: Successful technology transfer strategies in combating resistance to medication-assisted treatment