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

So who are the participants in this endeavor?

An Introduction to SAMHSA/CSAT

SAMHSA/CSAT

• 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. 

CSAT’s Mission:

The ATTC Network

The ATTC Network

ATTC ofNew England

NortheastATTC

PacificSouthwest

ATTC

NorthwestFrontier

ATTC

Prairielands ATTC

Mid-AmericaATTC

Great LakesATTC

Gulf Coast ATTC

MountainWestATTC

Mid-Atlantic ATTC

Southern CoastATTC

Southeast ATTC

Central EastATTC

Caribbean Basin, Hispanic/Latino & US Virgin Islands

ATTC

Central East ATTC

NorthwestFrontier

ATTC

ATTC National Office

An Introduction to NIDA

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

So what is this thing called the CTN?

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

CTN RRTC

States with CTP

CTN NodesCTN Nodes

Regional Research &

Training Center

Community Treatment Program

Community Treatment Program

Community Treatment Program Community

Treatment Program

Community Treatment Program

CTN Node

Community Treatment Program

Community Treatment Program

Community Treatment Program

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

Current Blending Teams

• Buprenorphine Awareness

• S.M.A.R.T. Treatment Planning

• Buprenorphine Detoxification

• Motivational Interviewing (MIA:STEP)

• Motivation Incentives (PAMI)

NIDA/SAMHSA-ATTC InitiativeBlending Team

Buprenorphine Treatment: A Training for Multidisciplinary

Addiction Professionals

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 ATTCNIDA Members:• Leslie Amass, Friends Research Institute, Inc.• Greg Brigham, CTN Ohio Valley Node• Eric Strain, Johns Hopkins University

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.

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

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

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

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

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

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

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.

NIDA/SAMHSA-ATTC InitiativeBlending Team

S.M.A.R.T. Treatment Planning: Utilizing the Addiction Severity Index

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

S.M.A.R.T Treatment Planning Utilizing the Addiction Severity Index

• S pecific

• M easurable

• A ttainable

• R ealistic

• T ime related

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

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

• Training manual including trainer notes and PowerPoint slides

• On-line training program

• Additional products– Quick guide– Lesson plans– Bibliography

S.M.A.R.T Treatment Planning Utilizing the Addiction Severity Index

• 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.

S.M.A.R.T Treatment Planning Course Content

NIDA/SAMHSA-ATTC InitiativeBlending Team: Buprenorphine

for Opioid Detoxification

Based on Results from

CTN Protocols for Inpatient Detox (CTN0001) and Outpatient Detox (CTN0002)

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 EnglandNIDA Members:• Greg Brigham, CTN Ohio Valley Node• Judy Harrer, CTN Ohio Valley Node• Dennis McCarty, CTN Oregon Node

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

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

Present and Opioid Negative 0001 (Inpatient)

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Day 3-4 Day 7-8 Day 10-11 Day 13-14

Clonidine Bup/Nx

Present and Opioid Negative 0002 (Outpatient)

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Day 3-4 Day 7-8 Day 10-11 Day 13-14

Clonidine Bup/Nx

NNT: Number Needed to Treat

NNT= Number of patients needed to treat

to achieve 1 treatment success

CTN 0001 (Inpatient)• NNT for Bup/Nx 77/59 = 1.31 • NNT for Clonidine 36/8 = 4.5

NNT Clonidine : BupNx = 3.44

CTN 0002 (Outpatient)• NNT for Bup/Nx: 157/46 = 3.4 • NNT for Clonidine: 74/4 = 18.5

NNT Clonidine : Bup/Nx = 5.44

Motivational Interviewing Assessment: Supervisory Tools for Enhancing

Proficiency (MIA:STEP)

NIDA/SAMHSA-ATTC InitiativeBlending Team

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 ATTCNIDA Members:• Samuel Ball, CTN New England Node• John Hamilton, CTN New England Node• Steve Martino, CTN New England Node

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

Implementing MI may require:

• Focused clinical supervision

• Audio taped MI Assessment sessions

• Tape coding

• Feedback, coaching and instruction for improving skills

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

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

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

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

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.

MI Assessment “Sandwich”

MI strategies during 1MI strategies during 1stst 20 min 20 min

MI strategies during last 20 minMI strategies during last 20 min

Agency Intake or Agency Intake or AssessmentAssessment

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

MIA:STEP Toolkit Overview

1. Briefing materials2. Summary of the MI Assessment

intervention3. Results of the NIDA CTN Research4. Teaching tools for enhancing and assessing

MI skills5. Tape rating guide and demonstration

materials6. Supervisor training curriculum

Promoting Awareness of Motivational Incentives (PAMI)

NIDA/SAMHSA-ATTC InitiativeBlending Team

Promoting Awareness of Motivational Incentives (PAMI)

Blending Team Members

ATTC Members:• Lonnetta Albright, Great Lakes ATTC, Chair• Joe Rosenfeld, Great Lakes ATTC• Amy Shanahan, Northeast ATTC• Anne Helene Skinstad, Prairielands ATTCNIDA Members:• John Hamilton, CTN New England Node• Scott Kellogg, CTN New York Node• Therese Killeen, CTN South Carolina Node

Rationale for Developing the PAMI Blending Package

•Research has shown that motivational incentive programs using low-cost reinforcement (prizes, vouchers, clinic privileges, etc.), delivered in conjunction with onsite urine screening promotes higher rates of treatment retention and abstinence from drug abuse. •This Blending Team is focusing its efforts on informing the field about successful approaches in the use of motivational incentives (also referred to as contingency management).

Motivational Incentives for Enhanced Drug Abuse

Recovery

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Improved Retention in Counseling Treatment

50% vs. 35% retained in the 12-week study using low-cost incentives.

Motivational Incentives for Enhanced Drug Abuse

Recovery

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Treatment as Usual

Treatment as Usualplus Incentives

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Incentives Improve Outcomes in Methamphetamine Users

46% vs. 30% presented negative results when tested for Methamphetamines.

Motivational Incentives for Enhanced Drug Abuse

Recovery

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Treatment as Usual

Treatment as Usualplus Incentives

Study Visit

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Incentives Reduce Stimulant use in Methadone Maintenance Treatment

61% vs. 31% presented negative results when tested for stimulants.

Goals of the PAMI Blending Package

•Designed to acquaint the addiction treatment field with Motivational Incentives as a science-based therapeutic strategy.•Elements incorporate examples of successful MI principles and strategies including the Fishbowl method.•Illustrates positive outcomes and lessons learned from the NIDA Motivational Incentives Enhanced Drug Abuse Recovery (MEIDAR) CTN study.

PAMI Blending Team Products

Blending Team products are currently being developed and will include a:•Awareness video•PowerPoint presentation •Brochure•Resource CD•Tool Kit (supporting materials)

For more informationContact your Regional ATTC

ATTC ofNew England

NortheastATTC

PacificSouthwest

ATTC

NorthwestFrontier

ATTC

Prairielands ATTC

Mid-AmericaATTC

Great LakesATTC

Gulf Coast ATTC

MountainWestATTC

Mid-Atlantic ATTC

Southern CoastATTC

Southeast ATTC

Central EastATTC

Caribbean Basin, Hispanic/Latino & US Virgin Islands

ATTC

Central East ATTC

NorthwestFrontier

ATTC

ATTC National Office

More Information and Regional ATTC Web Pages Can Be Found

at:

ATTC National Office

www.nattc.org

The End

For more information, please contact:

• Beth Rutkowski, M.P.H., (310) 267-5376 finnerty@ucla.edu

• Thomas Freese, Ph.D., (310) 267-5397 tefreese@ix.netcom.com