Adoption of Evidence-Based Practices in the CTN

1
Adoption of Evidence-Based Practices in the CTN

• Paul M. Roman Amanda J. Abraham
• University of Georgia
• Presentation at the NIDA Clinical Trials Network
  10th Anniversary Symposium, April 21, 2010
• Albuquerque, New Mexico

2
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

3
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 (N318)
  
• Privately funded programs (N345)

4
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

5
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?

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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

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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

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Latest Findings from the Platform Study
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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.

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Adoption of Buprenorphine over 4 year period in
the CTN Cross-sectional data
11
Adoption of Buprenorphine over 4 year period in
the CTN Longitudinal data (N129)
41
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Barriers to Buprenorphine Adoption among
non-adoptersRoman, Abraham, Rothrauff,
Knudsen. 2010. Journal of Substance Abuse
Treatment, 38(4) S44-S52.

• OTPs (N21)
• Cost associated with buprenorphine (23.8)
• Lack of access to a waivered physician (19.0)
• Non-OTPs, do not prescribe any medications
  (N156)
• 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 (N40)
• Cost of buprenorphine (17.5)
• Prescriber did not have a buprenorphine waiver
  (17.5)
• Current medical personnel prefer not to prescribe
  buprenorphine (10)

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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.

14
Adoption of Motivational Incentives over 4 year
period in the CTN Cross-sectional data
15
Adoption of Motivational Incentives over 4 year
period in the CTN Longitudinal data (N124)
61
16
Barriers to MI/CM adoption among
non-adoptersRoman, Abraham, Rothrauff,
Knudsen. 2010. Journal of Substance Abuse
Treatment, 38(4) S44-S52.

• Cost associated with implementation (32.5)
• Lack of compatibility with programs
  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
  programs population (10.6)

17
Adoption of Alcohol Pharmacotherapies in CTN and
Non-CTN Programs

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

18
Data

• Pooled sample of publicly funded CTN and non-CTN
  programs
• 127 CTN programs
• 147 Non-CTN programs
• Utilized data collected at baseline (2002-2004)
  and 24-month follow-up

19
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.
20
Early Adoption of acamprosate
21
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

22
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

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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.

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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

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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

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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