The NIDA/SAMHSA-ATTC Blending Initiative: New Tools for Bringing Research into Clinical Settings

1. The NIDA/SAMHSA-ATTC Blending Initiative: New Tools for Bringing Research into Clinical Settings Beth Rutkowski, M.P.H., & Thomas Freese, Ph.D. UCLA Integrated Substance Abuse Programs/Pacific Southwest Addiction Technology Transfer Center www.uclaisap.org www.psattc.org

2. So who are the participants in this endeavor?

3. An Introduction to SAMHSA/CSAT

4. SAMHSA/CSAT CSAT’s Mission: • To improve the lives of individuals and families affected by alcohol and drug abuse by ensuring access to clinically sound, cost-effective addiction treatment that reduces the health and social costs to our communities and the nation. • CSAT's initiatives and programs are based on research findings and the general consensus of experts in the addiction field that, for most individuals, treatment and recovery work best in a community-based, coordinated system of comprehensive services. • Because no single treatment approach is effective for all persons, CSAT supports the nation's effort to provide multiple treatment modalities, evaluate treatment effectiveness, and use evaluation results to enhance treatment and recovery approaches. 

5. The ATTC Network

6. NorthwestFrontierATTC Prairielands ATTC ATTC ofNew England NortheastATTC Great LakesATTC ATTC National Office MountainWestATTC Central East ATTC Mid-AmericaATTC Central EastATTC Mid-Atlantic ATTC PacificSouthwestATTC Southeast ATTC Gulf Coast ATTC Southern CoastATTC NorthwestFrontierATTC Caribbean Basin, Hispanic/Latino & US Virgin Islands ATTC The ATTC Network

7. An Introduction to NIDA

8. NIDA's mission is to lead the Nation in bringing the power of science to bear on drug abuse and addiction

9. So what is this thing called the CTN?

10. NIDA’s Clinical Trials Network • Established in 1999 • NIDA’s largest initiative to blend research and clinical practice by bringing promising therapies to community treatment providers • Network of 17 University-based Regional Research and Training Centers (RRTCs) involving 116 Community Treatment Programs (CTPs) in 24 states, Washington D.C., and Puerto Rico

11. CTN Nodes CTN RRTC States with CTP

12. CTN Node Community Treatment Program Community Treatment Program Community Treatment Program Regional Research & Training Center Community Treatment Program Community Treatment Program Community Treatment Program Community Treatment Program Community Treatment Program

13. Goals of the Agreement • Take “what we know” from NIDA-funded research and produce products for use by addiction field: • Training materials • Pamphlets • Bibliographies/reading materials • On-line courses

14. Current Blending Teams • Buprenorphine Awareness • S.M.A.R.T. Treatment Planning • Buprenorphine Detoxification • Motivational Interviewing (MIA:STEP) • Motivation Incentives (PAMI)

15. NIDA/SAMHSA-ATTC InitiativeBlending Team Buprenorphine Treatment: A Training for Multidisciplinary Addiction Professionals

16. Buprenorphine Awareness Blending Team Members ATTC Members: • Thomas Freese, Pacific Southwest ATTC, Chair • Beth Finnerty, Pacific Southwest ATTC • Glenda Clare, Central East ATTC • Gail Dixon, Southern Coast ATTC NIDA Members: • Leslie Amass, Friends Research Institute, Inc. • Greg Brigham, CTN Ohio Valley Node • Eric Strain, Johns Hopkins University

17. Goals for the Bup Awareness Blending Team • Creation of a package of materials to increase the awareness of the usefulness of buprenorphine for treating opiate addiction among non-physician practitioners. • To provide information designed to increase motivation for bringing buprenorphine to local communities as a treatment option • To provide information relevant to non-physician providers about what to expect when someone is treated with buprenorphine.

18. Bup Awareness Blending Team Products • Standup Training Package • 5-6 hour awareness training • 20-minute stand alone introduction • CEATTC On-line Course • Self-paced option • Additional Materials • Brochures • National Office Annotated Bibliography

19. Blending Team Products • Standup Training Package – 6 modules • Module I: Introduction to Opioid Treatment • What leads to opiate addiction • History of opiate treatment • Receptor pharmacology • Use of agonists, partial agonists, and antagonists in treatment

20. Blending Team Products • Standup Training Package – 6 modules • Module II/III: Buprenorphine/Opiate 101 • Overview of the medication and how it works • The role of buprenorphine in treatment • Induction • Maintenance • Medically-Assisted Withdrawal

21. Blending Team Products • Standup Training Package – 6 modules • Module IV: Identification of Patients for Buprenorphine Treatment • Where are opiate dependent patients seen? • Screening and identification of opiate dependent individuals • Ways for providers to facilitate treatment • Understanding who is an optimal candidate for buprenorphine treatment

22. Blending Team Products • Standup Training Package – 6 modules • Module V: Coordinated Care • How to find a physician who can prescribe Bup • Roles of providers • Working within the scope of practices/using linkages to other providers • No wrong door to treatment

23. Blending Team Products • Standup Training Package – 6 modules • Module VI: Counseling Buprenorphine Patients • Craving and Triggers • Working with Special Populations • Buprenorphine-Related Patient Management Issues

24. Key Components of this Package • Available through the 14 regional ATTCs and 17 Nodes of the CTN. • Designed to be completely customizable to meet the needs of each state. • An important new resource for your states to assist in integrating this important new treatment in local treatment environments.

25. NIDA/SAMHSA-ATTC InitiativeBlending Team S.M.A.R.T. Treatment Planning: Utilizing the Addiction Severity Index

26. S.M.A.R.T. Treatment Planning Blending Team Members ATTC Members: • Richard Spence, Gulf Coast ATTC, Chair • Nancy Roget, Mountain West ATTC • Pat Stilen, Mid-America ATTC NIDA Members: • Deni Carise, Treatment Research Institute • Meghan Love, Treatment Research Institute • A. Thomas McLellan, Treatment Research Institute

27. S.M.A.R.T Treatment Planning Utilizing the Addiction Severity Index • S pecific • M easurable • A ttainable • R ealistic • T ime related

28. S.M.A.R.T. Treatment Planning • Goal and Focus: • Transform required paperwork (e.g., ASI, psychosocial assessment) into clinically useful information • The focus of the training is on incorporating the assessment information in treatment planning and using the treatment plan to guide service delivery

29. S.M.A.R.T. Treatment Planning • Information covered: • Addiction Severity Index (ASI) application in treatment planning • Individualized treatment plans vs. program-driven plans • Evaluation uses for program directors and clinical supervisors • Role of treatment plan in clinical records • Experiential writing exercises

30. S.M.A.R.T Treatment Planning Utilizing the Addiction Severity Index • Training manual including trainer notes and PowerPoint slides • On-line training program • Additional products • Quick guide • Lesson plans • Bibliography

31. S.M.A.R.T Treatment Planning Course Content • Module 1: Learn how the results from administering the ASI can make a counselor’s task easier and be able to discern differences between program-driven and individualized treatment plans • Module 2: Identify and understand individualized treatment plans and how these plans can improve client retention/treatment outcomes • Module 3: Practice formulating treatment plans using ASI information • Module 4: Practice formulating documentation notes based on treatment plan progress.

32. NIDA/SAMHSA-ATTC InitiativeBlending Team: Buprenorphine for Opioid Detoxification Based on Results from CTN Protocols for Inpatient Detox (CTN0001) and Outpatient Detox (CTN0002)

33. Buprenorphine Detox Blending Team Members ATTC Members: • Thomas Freese, Pacific Southwest ATTC, Chair • Beth Finnerty, Pacific Southwest ATTC • Kay Gresham Morrison, Southeast ATTC • Steven Gumbley, ATTC of New England NIDA Members: • Greg Brigham, CTN Ohio Valley Node • Judy Harrer, CTN Ohio Valley Node • Dennis McCarty, CTN Oregon Node

34. Buprenorphine for Opioid Detoxification Goals: • Training for physicians to conduct the 13-day buprenorphine taper evaluated through the CTN studies. • Information for other multidisciplinary treatment personnel to support patients who are receiving this treatment

35. Buprenorphine Detox Blending Team Products • Four hour classroom training program providing instruction on using buprenorphine for opioid dependent patients. Including: • Rational for providing detoxification to opioid dependent patients • Characterization of opiate withdrawal • Goals of detoxification • Results of the CTN studies • Implementation training • Patient and treatment staff perspectives • Overdose risk following detoxification

36. Present and Opioid Negative 0001 (Inpatient)

37. Present and Opioid Negative 0002 (Outpatient)

38. NNT: Number Needed to Treat • CTN 0001 (Inpatient) • NNT for Bup/Nx 77/59 = 1.31 • NNT for Clonidine 36/8 = 4.5 • NNT Clonidine : BupNx = 3.44 NNT= Number of patients needed to treat to achieve 1 treatment success • CTN 0002 (Outpatient) • NNT for Bup/Nx: 157/46 = 3.4 • NNT for Clonidine: 74/4 = 18.5 • NNT Clonidine : Bup/Nx = 5.44

39. NIDA/SAMHSA-ATTC InitiativeBlending Team Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP)

40. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP) Blending Team Members ATTC Members: • Steven Gallon, Northwest Frontier ATTC, Chair • Sherry Ceperich, Mid-Atlantic ATTC • Maria del Mar Garcia, Caribbean Basin & Hispanic ATTC • Denise Pyle, Mid-Atlantic ATTC • Edna Quinones, Caribbean Basin & Hispanic ATTC NIDA Members: • Samuel Ball, CTN New England Node • John Hamilton, CTN New England Node • Steve Martino, CTN New England Node

41. What is an MI Assessment? • Use of client-centered MI style • MI strategies that can be integrated into the agency’s existing intake assessment process • Methods that can be used with diverse substance use problems • Skills for assisting clients in assessing their own substance use • Understanding the client’s perception and willingness to enter into a treatment process

42. Implementing MI may require: • Focused clinical supervision • Audio taped MI Assessment sessions • Tape coding • Feedback, coaching and instruction for improving skills

43. Benefits of MI Assessment • It has a solid evidence-base • MI improves client engagement and retention • Using MIA:STEP: • Enhances clinical supervision • Builds counselor knowledge and proficiency in MI

44. Why another application of MI? • Positive outcomes depend on clients staying in treatment for adequate length of time • Adding MI at beginning of treatment increases client retention • The type of clinical supervision needed to maintain and improve MI skills is generally lacking

45. The costs of implementing MI Assessment • Time to learn and implement the protocol • Regular review and feedback on MI skills • Ongoing clinical supervision, including: - Training - Mentoring - Practice - Review of recorded interviews - Feedback - Development of learning plans • The cost of recorders and supplies

46. Why consider this approach when staff are already trained in MI? • Most trained clinicians do not use MI appropriately, effectively or consistently • MI is more difficult than clinicians expect • The key to successful implementation of MI is supervisory feedback and coaching

47. Development of the protocol • The NIDA Drug Abuse Treatment Clinical Trials Network designed the protocol • Designed as something that all outpatient community treatment providers could use • Researchers worked directly with MI experts and treatment providers on both development and implementation.

48. MI strategies during 1st 20 min Agency Intake or Assessment MI strategies during last 20 min MI Assessment “Sandwich”

49. MIA:STEP Toolkit includes everything you need to: • Introduce the idea of doing an MI assessment • Train counselors and supervisors • Provide ongoing supervision of MI • Train supervisors to use a simple tape rating system • Use an MI style of supervision

50. MIA:STEP Toolkit Overview • Briefing materials • Summary of the MI Assessment intervention • Results of the NIDA CTN Research • Teaching tools for enhancing and assessing MI skills • Tape rating guide and demonstration materials • Supervisor training curriculum