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Integrated Substance Abuse Programs. Bridges have been built: Is anyone using them? Richard A. Rawson, Ph.D, Professor Supported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) United Nations Office of Drugs and Crime .

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Integrated Substance Abuse Programs

Bridges have been built: Is anyone using them?Richard A. Rawson, Ph.D, ProfessorSupported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) United Nations Office of Drugs and Crime

the problem in 1996
The Problem in 1996
  • The US Substance Abuse Research and Treatment Systems each spend billions of dollars per year on the problem of substance abuse treatment.
  • However, the efforts have traditionally been completely disconnected. Despite over 30 years of research findings, most treatment services are based on practices developed during the 1950s and 1960s.
u s agencies involved with substance abuse research and treatment
U.S. Agencies Involved with Substance Abuse Research and Treatment

Research Agencies


National Institutes of Health


National Institute on Drug Abuse


National Institute on Alcohol Abuse & Alcoholism

u s agencies involved with substance abuse research and treatment1
U.S. Agencies Involved with Substance Abuse Research and Treatment

Service Agencies


Substance Abuse, Mental Health Services Administration


Center for Substance Abuse Treatment


Center for Substance Abuse Prevention

traditional culture of u s substance abuse research system
Traditional “Culture” of U.S. Substance Abuse RESEARCH System
  • University-based, academic personnel
  • Minimal community involvement
  • Treatment viewed condescendingly
  • Publish data in professional journals
  • Little systematic attempt to transfer knowledge
  • Topics of research omit clinical concerns
traditional culture of u s substance abuse service delivery system
Traditional “Culture” of U.S. Substance Abuse SERVICE Delivery System
  • Recovering/paraprofessional staff
  • Minimal connections with academic tradition
  • Personal ideology determines treatment choices
  • Generally anti-medication
  • Uneven and inadequate treatment funding
  • Little attention to data
  • Science viewed as irrelevant
bridging the gap a benchmark
“Bridging the Gap”: A Benchmark
  • Institute of Medicine (1998). S. Lamb, M.R. Greenlick, & D. McCarty, D. (Eds.), Bridging the gap between practice and research: Forging partnerships with community-based drug and alcohol treatment. Washington, DC: National Academy Press.
nida clinical trials network ctn
NIDA Clinical Trials Network (CTN)
  • MissionThe mission of the Clinical Trials Network (CTN) is to improve the quality of drug abuse treatment throughout the country using science as the vehicle.The CTN provides an enterprise in which the National Institute on Drug Abuse, treatment researchers, and community-based service providers cooperatively develop, validate, refine, and deliver new treatment options to patients in community-level clinical practice. This unique partnership between community treatment providers and academic research leaders aims to achieve the following objectives:
  • Conducting studies of behavioral, pharmacological, and integrated behavioral and pharmacological treatment interventions of therapeutic effect in rigorous, multi-site clinical trials to determine effectiveness across a broad range of community-based treatment settings and diversified patient populations; and
  • Ensuring the transfer of research results to physicians, clinicians, providers, and patients.
the nida ctn what is it
The NIDA CTN: What is it?
  • Network Organization
  • The CTN framework consists of seventeen Nodes (Regional Research and Training Centers, linked with five to ten or more Community-based Treatment programs), a Clinical Coordinating Center, and a Data and Statistical Center. 
  • This allows the CTN to provide a broad and powerful infrastructure for rapid, multi-site testing of promising science-based therapies and the subsequent delivery of these treatments to patients in community-based treatment settings across the country.
the pacific node of the ctn
The Pacific Node of the CTN
  • The Pacific Region Node is a partnership between the Regents of the University of California, Los Angeles and several community treatment programs in the State.
  • The Pacific Node incorporates researchers and clinicians from throughout California. Many of the clinical networks have been involved in the transfer of research into practice for over a decade
nida ctn how does it work
NIDA CTN: How does it work?
  • Research concepts are generated at each of the Nodes after discussion between researchers and clinicians.
  • These concepts are proposed to the CTN group and are voted on. Those receiving highest vote go to director of NIDA for approval.
pacific region protocol involvement
Pacific Region Protocol Involvement

PROTOCOL0001 Buprenorphine/Naloxone for Opiate Detoxification - INpatient

  • PROTOCOL0002 Buprenorphine/Naloxone for Opiate Detoxification - OUTpatient
  • PROTOCOL0004 Motivational Enhancement Treatment (MET)
  • PROTOCOL0006 Motivational Incentives - Drug Free Clinics
  • PROTOCOL0007 Motivational Incentives - Methadone Clinics
  • PROTOCOL0008 A Baseline for Investigating Diffusion of Innovation
pacific region protocol involvement1
Pacific Region Protocol Involvement
  • PROTOCOL0009 Smoking Cessation Treatment With Transdermal Nicotine Replacement Therapy In Substance Abuse Rehabilitation Programs
  • PROTOCOL0012 Characteristics of Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C Viral Infection, and Sexually Transmitted Infections in Substance Abuse Treatment Programs
  • PROTOCOL0014 Brief Strategic Family Therapy (BSFT) For Adolescent Drug Abusers
pacific region protocol involvement2
Pacific Region Protocol Involvement
  • PROTOCOL0018 Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment
  • PROTOCOL0019 Reducing HIV/STD Risk Behaviors: A Research Study for Women in Drug Abuse Treatment
  • PROTOCOL0027 Starting Treatment with Agonist Replacement Therapies – START
  • PROTOCOL0030 Prescription Opioid Addiction Treatment Study (POATS)
ctn strengths
CTN: Strengths
  • Has provided a true forum for researchers and clinicians to interact cooperatively and collaboratively
  • Has generated a significant amount of new published research
  • Research and surrounding publications do appear to be promoting some transfer of research to practice in CTN-affiliated treatment organizations
  • Annual “Blending” Conference and Journal
ctn limitations opinion
CTN: Limitations (opinion)
  • Extremely expensive
  • Extremely bureaucratic and committee heavy
  • Productivity not commensurate with budget
  • Bi-directionality of effort is only moderately successful (mostly researcher driven)
  • Impact on the larger US treatment system is unknown
running the trials is not enough
Running the Trials is not enough
  • Diffusion of Innovations. 4th Edition
  • Everett M. Rogers - 1995 - New York: Free Press
research questions
Research Questions
  • NIDA’s CTN offers an important opportunity to examine if and how inter-organizational relationships promote innovation adoption
    • Focus on buprenorphine and voucher-based motivational incentives
  • Are CTPs in the CTN protocols significantly more likely to adopt bup and/or vouchers?
    • Is “trialability” a predictor of adoption?
  • Does membership in the CTN confer advantages to CTPs that are not involved in these protocols?
    • Is “exposure” a predictor of adoption?
adoption of buprenorphine
Adoption of Buprenorphine

CTPs that participated in the buprenorphine trials were significantly more likely to have adopted buprenorphine than CTPs not in the trials and non-CTN centers

logistic regression model of buprenorphine adoption
Logistic Regression Model of Buprenorphine Adoption
  • Controlling for other organizational factors:
    • CTPs in the buprenorphine protocols were 5.2 times more likely to use buprenorphine (at the 6-month follow-up) than non-CTN programs (p<.01)
  • Other significant predictors, net of effects of CTN exposure:
    • Center offers detox services (O.R. = 3.59)
    • Center has a physician on staff or contract (O.R. = 3.94)
    • The percentage of primary opiate clients (O.R. = 1.009)
adoption of voucher based motivational incentives
Adoption of Voucher-Based Motivational Incentives

These differences in adoption were not statistically significant

  • The ability to compare CTN vs. non-CTN centers provides a unique opportunity to examine a variety of factors that influence innovative behavior and the adoption of evidence-based practices at the organizational level.
  • The longitudinal design of these studies will allow for observation of continued trends in adoption of these techniques.
  • Future research is planned to examine the use of MET and motivational interviewing in CTN and non-CTN samples.
from a clinical trial to technology transfer
From a clinical trial to technology transfer
  • S. Kellogg, M. Burns, P. Coleman, M. Stitzer, J. Wale, M. Jeanne Kreek, M.D.
  • Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. 
  • Journal of Substance Abuse Treatment, 2005, Volume 28, Issue 1, Pages 57-65
mctg the problem
MCTG: The Problem
  • NIDA has a desire to speed up the development of medications for the treatment of methamphetamine use disorders.
  • Too few research groups available in areas of the US with extensive methamphetamine use.
  • As complexity of medication testing and regulatory system becomes more complex it is difficult for new investigators to initiate research
mctg the solution
MCTG: The Solution
  • Establish a training/coordinating center to train, organize and monitor sites.
  • Establish a set of medication testing sites in regions with extensive methamphetamine use and an MD and team that can conduct trials.
  • Decide on a medication(s) and protocol for study
  • Initiate studies
methamphetamine clinical trials group
Methamphetamine Clinical Trials Group
  • UCLA is the coordinating center for clinical studies
  • 5 Sites participate on a contractual basis
  • Primary focus-reduction of methamphetamine use
  • All trials use a behavioral platform for all treated subjects

Costa Mesa, CA

Friends Research Institute

Michael McCann, PI

Des Moines, IA Powell Chemical Dependency Center

Dennis Weis, PI

San Diego, CA

South Bay Treatment Center

Joseph Mawhinney, PI

Kansas City, MO

University of Missouri, Kansas City

Services, Inc.

Jan Campbell, PI

Honolulu, HI

John A. Burns School of

Medicine & Queens Hospital

William Haning, PI

Methamphetamine Clinical Trials Group


Los Angeles, CA

UCLA Coordinating Center

Richard Rawson, PI

Division of Treatment Research & Development 19 September 2000

mctg studies
MCTG Studies
  • Behavioral Platform Study (Completed Oct, 2002). (N=60)
  • Ondansetron Study ( Completed Dec 1, 2003. (N=120
  • Bupropion Study (Completed June 1, 2005) (N=120)
  • Topirimate Study (Underway, projected completion, April 1, 2007 (N=120)
  • Modafinal Study (Projected to begin April 2007)
mctg accomplishments
MCTG: Accomplishments
  • Transferred state-of-the-art clinical trials methods to clinical sites with no previous research experience.
  • Successful conducted 3 studies to date with one (bupropion) showing significant promise
  • Sites now are capable of applying for independent research funding

Process Improvement 101

Reduce Waiting & No-Shows  Increase Admissions & Continuation

why process improvement
Why Process Improvement?
  • Customers are served by processes
  • 85% of customer related problems arecaused by organizational processes
  • To better serve customers, organizationsmust improveprocesses
niatx four project aims
NIATx Four Project Aims

Reduce Waiting Times

Reduce No-Shows

Increase Admissions

Increase Continuation Rates

niatx results
NIATx Results

Reduce Waiting Times:51% reduction

(37 agencies reporting)

Reduce No-Shows: 41% reduction

(28 agencies reporting)

Increase Admissions: 56% increase

(23 agencies reporting)

Increase Continuation: 39% increase

(39 agencies reporting)


Five Key Principles

Evidence-based predictors of change

  • Understand & Involve the Customer
  • Focus on Key Problems
  • Select the Right Change Agent
  • Seek Ideas from Outside the Field and Organization
  • Do Rapid-Cycle Testing
understand and involve the customer
Understand and Involve the Customer
  • Most important of all the Principles
  • What is it like to be a customer? Staff are customers, too!
  • Walk-through, focus groups…
focus on key problems
Focus on Key Problems
  • What is keeping the executive director awake at night?
  • What processes have staff and customers identified as barriers to excellent service?
detour 1
Detour 1

Unclear purpose!

  • Where are you going?
  • How will you know you have arrived?
aim statement
Aim Statement
  • Example
    • Improve 30-day continuation rates from 30% to 80% in outpatient services.
  • Need
    • Target
    • Scope of work
detour 2
Detour 2

No feedback!

  • Need a tracking measure.
  • Have a simple measure.

The Problem:California Prison Population, Drug Offenses, 1980-2000

Source: California Department of Corrections.

increase in california prison population drug offenses 1970 1999 rate per 100 000 population
Increase in California Prison Population, Drug Offenses, 1970-1999Rate per 100,000 Population

Source: California Department of Corrections.

proposition 36 substance abuse crime prevention act sacpa
Proposition 36Substance Abuse & Crime Prevention Act (SACPA)
  • 2000 Ballot Measure: Passed by 61% of California voters in 2000
  • Authorized $600,000,000 in new funds for implementation. 2001-2006.
  • Drug offenses: Non-sales, non-manufacturing.
  • Restrictions on offenders with histories of serious or violent crimes
  • Results in community supervision and treatment instead of: Incarceration or

supervision without treatment

2000 proposition 36 ballot wording
2000 Proposition 36 Ballot Wording:

Proposition 36. Drugs. Probation and Treatment Program. Requires probation and drug treatment, not incarceration, for possession, use, transportation of controlled substances and similar parole violations, except sale or manufacture. Authorizes dismissal of charges after completion of treatment.


6,199,992 / 60.8% Yes votes 3,991,153 / 39.2% No votes

Proposition 36 passed and was enacted as the:

Substance Abuse & Crime Prevention Act



Arrest or



Conviction and Court Order of Probation and Treatment; or Parole Referral






















client characteristics
Client Characteristics
  • Half use methamphetamines
  • Half used primary drug more than 10 years
  • Half are in treatment for first time
treatment summary
Treatment Summary
  • 34% of clients who enter treatment complete it
  • Most clients are sent to outpatient treatment
  • Heroin users rarely get methadone treatment
  • Heroin users are least likely to complete

Any Work in the Past 30 Days

a,b Group differences are statistically significant, p = .04. Pre-post differences (not shown) are all

statistically significant, p <.0001.


Any Drug Use in the Past 30 Days

Group differences are statistically significant. ap<.05, bp<.02.

outcome summary effect of sacpa as policy
Outcome Summary: Effect of SACPA As Policy
  • SACPA-era offenders have more drug arrests in the initial 12 months
  • Initial re-offending is affected by differences in incarceration rates
  • Violent re-offending is low in all groups


Notes: Figure provides a summary of cost offsets. The zero-line can be interpreted as cost neutral. Any bar above the line represents a cost increase and any bar below the line represents a cost saving.



  • Savings primarily from prison, jail reductions.
  • Cost increases primarily from increased treatment, new crimes.
  • Costs are $2,861 per offender lower than what we would expect in the absence of SACPA.
  • Benefit-to-cost ratio of about 2.5:1.
  • For treatment completers, the cost savings reflect a benefit-to-cost ratio of about 4:1


  • Substantially reduced incarceration costs.
  • Greater cost savings for some offenders than for others
  • Can be improved

California Prison Population, Drug Offenses, 1980-2000

Source: California Department of Corrections.


California Prison Population, Drug Offenses, 1980-2004

Source: California Department of Corrections.

  • 70% of referrals have entered treatment
  • Methamphetamine is the most common drug
  • Half are in treatment for the first time
  • 34% of clients have completed treatment
  • Initial re-offending is lowest for completers
  • Employment is highest for completers
  • Abstinence is highest for completers, but overall drug use outcomes are uneven
prop 26 sacpa is it good policy
Prop 26 (SACPA): Is it good policy?
  • Approximately 200,000 individuals will have received treatment over program
  • Final report currently in process
    • Fiscal impact appears quite positive
  • No group has come out to revoke SACPA
  • Disagreements concern exact provisions
  • Failure to pass revised SACPA provisions could result in funding responsibility being passed on to counties.
Recognizing and Addressing the Need to Expand Training and Treatment Capacity to Address Substance Abuse Problems
  • There is a need for trained professionals to deliver effective rehabilitation and harm reduction interventions for substance abuse and dependence around the world
  • The paucity of properly trained professional is a barrier to the development and delivery of effective treatment services, especially regarding underserved and inappropriately served populations of drug abusers, including women and children
  • There is a worldwide shortage of qualified training experts and educational settings in which drug abuse treatment training is provided, particularly in developing regions
  • A goal of this training effort is to train clinicians and educate academics who will train additional professionals to address the problems of drug abuse in an empirically rational method
capacity building plan
Capacity Building Plan

In short, the goal of the capacity building plan is to increase the number of personnel who can disseminate and promote the use of effective, scientifically-supported and practical drug abuse treatment practices around the world.

treatnet members
Treatnet Members
  • RS Ketergantungan Obat The Drug Dependence Hospital, Indonesia
  • Iranian National Prison Organisation /Iranian National Centre for Addiction Studies INCAS, Iran
  • National Research and Clinical Centre on Medical and Social Problems of Drug, Kazakhstan
  • Drug Rehabilitation Unit, Mathari Hospital, Kenya
  • Centros de Integración Juvenil A.C., Mexico
  • Neuropsychiatric Hospital Aro, Nigeria
treatnet members1
Treatnet Members
  • Shanghai Drug Abuse Treatment Centre, China
  • Carisma Centre for Attention and Integral Mental Health, Colombia
  • General Secretariat of Mental Health, Egypt
  • TT Ranganathan Clinical Research Foundation, India
  • Regional Research Centre of Narcology and Psychopharmacology affiliated to St. Petersburg Pavlov State Medical University, Russia
  • Psychosocial Attention Centre for Alcohol and other Drugs, Brazil
treatnet members2
Treatnet Members
  • Turning Point Alcohol and Drug Centre Inc., Australia
  • Centre for Addiction and Mental Health CAMH, Canada
  • Mudra, Germany
  • Asociación Proyecto Hombre, Spain
  • Maria Ungdom, Sweden
  • Cranstoun Drug Services, United Kingdom
  • Fayette Companies, U.S.A.
  • Stanley Street Treatment & Resources (SSTAR) Inc., U.S.A.
capacity building plan for unodc treatnet program what are we trying to do
Capacity Building Plan for UNODC Treatnet Program: What are we trying to do?

The purpose of the capacity building component for the UNODC Treatnet Program is to develop a set of training materials and a training plan for trainers from 20 Resource Centres established by UNODC. To accomplish this task, we will:

1. Conduct a training needs assessment.

2. Determine priority training/skill development topics.

3. Create a set of training modules to address #2.

4. Conduct a set of training, supervision and mentoring activities with two trainers from each of the resource centres.

5. Collect information to contribute to the project evaluation.

need assessment a brief summary
Need Assessment: A Brief Summary

The following topics received the most interest.

  • Motivational Interviewing
  • Relapse Prevention (CBT)
  • Assessment
  • Program management
  • Outreach strategies
  • Youth
  • Building Service Networks
  • Family
  • Co-occurring
  • Drugs and the brain
  • Brief interventions
  • Outpatient treatments
  • Harm minimization
  • Basic knowledge of drugs
  • Research and evaluation methods
  • The issue of research practice integration has been a priority in the US for almost a decade.
  • Major initiatives have been established to cross the research-practice gap.
  • Clinicians are more aware of research value and findings
  • Quality research can be done in clinical service delivery settings
  • It continues to be a challenging, expensive, time consuming process
thank you