ADOPTION OF ADOPTION OF EVIDENCE-BASED EVIDENCE-BASED PRACTICES IN THE PRACTICES IN THE

CTNCTN

Paul M. Roman & Amanda J. AbrahamUniversity of Georgia

Presentation at the NIDA Clinical Trials Network 10th Anniversary

Symposium, April 21, 2010 Albuquerque, New Mexico

UGA PLATFORM STUDY OF CTN DEVELOPMENT AND IMPACT (2001-

PRESENT)

Goal of this Presentation: To explore organization-level adoption, implementation, and discontinuation of evidence-based treatment practices (EBPs)

Two types of data analysis Comparing the CTN to non-CTN programs Change within the CTN over time

Adoption of: Buprenorphine Motivational incentives/contingency

management Alcohol pharmacotherapies

METHODOLOGY Face-to-face interviews with administrators

and/or clinical directors of CTPs & mail/internet based surveys with counselors in CTPs

Three waves of data collection Baseline (2002-2004) 24 month follow-up 48 month follow-up

Comparisons with 2 nationally representative samples: Publicly funded programs (N=318) Privately funded programs (N=345)

DISSEMINATION AND THE CTN

Dissemination of the results of CTN trials is a major part of the CTN mandate

This mandate has moved into prominence as the results of trials have been rolled out

Research Utilization Committee has mobilized much energy and in collaboration with ATTCs

CTN continues to develop and refine “Blending Products” and conduct “Blending Conferences”

DISSEMINATION AND THE CTN (2)

“Dissemination science” is complex and developed in the context of commercial marketing and at the level of groups and individuals

weak at the organizational level

What is the proper performance measure of “dissemination responsibility” of the CTN?

To put information about new treatment options in front of organizational consumers?

Moving innovations “all the way” to implementation?

DISSEMINATION IN THE CTN (3) Implementation responsibility at the level of

the individual provider

Providers are a complex mix of public, non-profit and for-profit organizations, based in diverse settings

Providers need strategic planning and a business orientation in using disseminated knowledge from the CTN in making implementation investments

ADOPTION OF BUPRENORPHINE: SUMMARY

OF RESEARCH FINDINGS 1. Study comparing adoption of buprenorphine in

CTN and Non-CTN OTPs (Ducharme & Roman, 2009) CTN affiliation was significantly associated with

buprenorphine adoption

2. Study examining adoption of buprenorphine over 2 year period in the CTN (Knudsen, Abraham, Johnson & Roman, 2009) Baseline adoption of buprenorphine was positively

associated with continued use at 24m follow-up Buprenorphine protocol involvement was positively

associated with adoption Much of buprenorphine adoption at 24m follow-up was

in programs without protocol experience

LATEST FINDINGS FROM THE PLATFORM STUDY

ADOPTION OF BUPRENORPHINE OVER

A 4 YEAR PERIOD IN THE

CTN

Roman, Abraham, Rothrauff, & Knudsen. 2010. Journal of Substance Abuse Treatment, 38(4):

S44-S52.

ADOPTION OF BUPRENORPHINE OVER 4 YEAR PERIOD IN THE CTN: CROSS-

SECTIONAL DATA

ADOPTION OF BUPRENORPHINE OVER 4 YEAR PERIOD IN THE CTN: LONGITUDINAL

DATA (N=129)

41%

BARRIERS TO BUPRENORPHINE ADOPTION

AMONG NON-ADOPTERSROMAN, ABRAHAM, ROTHRAUFF, & KNUDSEN. 2010. JOURNAL OF

SUBSTANCE ABUSE TREATMENT, 38(4): S44-S52.

OTPs (N=21) Cost associated with buprenorphine (23.8%) Lack of access to a waivered physician (19.0%)

Non-OTPs, do not prescribe any medications (N=156) 38 programs did not have access to prescribing staff, so adoption

was not possible Regulatory barriers (25.9%) Inconsistent with treatment philosophy, better alternatives

available (18.5%) Liability issues (18.5%)

Non-OTPs, prescribe other medications (N=40) Cost of buprenorphine (17.5%) Prescriber did not have a buprenorphine waiver (17.5%) Current medical personnel prefer not to prescribe buprenorphine

(10%)

ADOPTION OF MOTIVATIONAL INCENTIVES OVER 4 YEAR PERIOD IN THE CTN

Roman, Abraham, Rothrauff, & Knudsen. 2010. Journal of Substance Abuse Treatment, 38(4):

S44-S52.

ADOPTION OF MOTIVATIONAL INCENTIVES OVER

4 YEAR PERIOD IN THE CTN: CROSS-SECTIONAL DATA

ADOPTION OF MOTIVATIONAL INCENTIVES ADOPTION OF MOTIVATIONAL INCENTIVES OVER 4 YEAR PERIOD IN THE CTN: OVER 4 YEAR PERIOD IN THE CTN:

LONGITUDINAL DATA (N=124)LONGITUDINAL DATA (N=124)

61%

BARRIERS TO MI/CM ADOPTION AMONG NON-ADOPTERS

ROMAN, ABRAHAM, ROTHRAUFF, & KNUDSEN. 2010. JOURNAL OF SUBSTANCE ABUSE TREATMENT, 38(4): S44-S52.

Cost associated with implementation (32.5%)

Lack of compatibility with program’s philosophy(15.4%)

Logistical issues such as competing demands, short length of stay, lack of a developed protocol for implementing MI/CM (11.4%)

Perceived ineffectiveness of MI/CM with the program’s population (10.6%)

ADOPTION OF ALCOHOL PHARMACOTHERAPIES IN CTN AND NON-CTN PROGRAMS

Abraham, Knudsen, Rothrauff, & Roman. 2010. Journal of Substance Abuse Treatment, 38(3): 275-283.

DATA

Pooled sample of publicly funded CTN and non-CTN programs127 CTN programs147 Non-CTN programs

Utilized data collected at baseline (2002-2004) and 24-month follow-up

ADOPTION OF TABLET NALTREXONE

FOR ALCOHOL DEPENDENCE

*Adoption of tablet naltrexone increased by 6.3% over time in the CTN and did not change in non-CTN programs.

EARLY ADOPTION OF ACAMPROSATE

KEY FINDINGSABRAHAM, KNUDSEN, ROTHRAUFF, & ROMAN. 2010. JOURNAL

OF SUBSTANCE ABUSE TREATMENT, 38(3): 275-283.

CTN participation was not a significant predictor of tablet naltrexone adoption at baseline

At 24-month follow-up, CTN programs were three times more likely than non-CTN programs to adopt tablet naltrexone net of program structure and culture, environmental

scanning, membership in a provider association, and administrator education

CTN programs were three times more likely than non-CTN programs to adopt acamprosate in 2006 net of program culture, environmental scanning,

membership in a provider association, and administrator education

SUMMARY OF PLATFORM STUDY FINDINGS

Successful adoption of buprenorphine in the CTN

Greater adoption of EBPs in CTN versus non-CTN treatment programs

Overall importance of research network in promoting adoption of EBPs

ACKNOWLEDGEMENTS

We gratefully acknowledge the research support of the National Institute on Drug Abuse (Grant No. R01DA14482, R21DA020028, and R01DA013110), and the participation of community treatment programs affiliated with the CTN in this research study.

AVAILABILITY OF PHYSICIANS

27% of CTN programs do not have a physician on staff/contract

Of programs with physicians: 54% of non-OTP CTN programs with a physician

on staff/contract do not prescribe alcohol pharmacotherapies

23% of CTN programs do not prescribe buprenorphine

AVAILABILITY OF PHYSICIANS: COMPARISONS TO THE PUBLIC AND PRIVATE

SECTOR

• 27% of CTN programs do not have a prescribing physician on staff/contract

• 23% of private programs do not have a prescribing physician on staff/contract

• 38% of public programs do not have a prescribing physician on staff/contract

PRESCRIPTION OF PHARMACOTHERAPIES: COMPARISON TO THE PUBLIC AND PRIVATE

SECTORS

• Of programs with a physician:• 41% of private programs with access to a physician

do not prescribe alcohol pharmacotherapies and 49% do not prescribe buprenorphine

• 82% of public programs with access to a physician do not prescribe alcohol pharmacotherapies and 67% do not prescribe buprenorphine

• 54% of non-OTP CTN programs with access to a physician do not prescribe alcohol pharmacotherapies and 23% of CTN programs do not prescribe buprenorphine