The CTN Research Utilization Committee: Putting Dissemination Research into Practice

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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

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

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The CTN Trials (1999 now)
Medical Interventions 9 Behavior
Interventions 11 HIV/HCV Interventions
4 Others 3
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I utilize the best from Freud, the best from
Jung, and the best from my Uncle Marty, a very
smart fellow.
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Patient Outcomes

• Effective intervention practices
• Effective implementation practices
• Good outcomes for Patients

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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.

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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 .

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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)

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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.

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Blending Initiative

• SAMHSA-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)
  
• 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

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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.)

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CTN Motivational Interviewing Trial

• Patients (n423) assigned to MI at intake
  subsequently completed more counseling sessions
  (mean5.02, sd5.15) than Standard Care patients
  (mean4.03, sd4.21) during 28 days after
  randomization (plt.05)
• MI patients more likely (84) to still be
  enrolled at the program after one month than
  Standard Care patients (75) (plt.04)

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Agreement about Occurrence
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Motivational Interviewing Assessment
M I A
Supervisory Tools for Enhancing Proficiency
STEP
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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

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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

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

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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

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MIA STEP Dissemination Model?
MIA STEP
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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

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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/library/MIA-S
  TEP.pdf is averaging 12,000 downloads per week!

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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

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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?

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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)

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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

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• Many thanks for your attention!