Research to practice

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Understanding Ohio X-Waivered Advanced Practice Registered Nurses' Rate of Naltrexone Prescription for Alcohol Use Disordered Patients

BACKGROUND

Alcohol use disorder (AUD) is overrepresented within the United States. Naltrexone, a recommended treatment for AUD, is underutilized. However, the prescribing behaviors of advanced practice registered nurses (APRNs) regarding naltrexone for AUD patients have not been studied. The purpose of our study was to explore the prescriptive practices of a sample of APRNs.

AIMS

To describe and analyze survey responses of a sample of Ohio APRNs with training in medication for addiction treatment (MAT) for substance use disorders (as evidenced by DEA x-waiver receipt) regarding prescribing practices of naltrexone for AUD patients.

METHOD

Public information collected from the first author's Nursing Board (list of APRNs in Ohio) was checked against the public information of x-waivered providers nationally from the Substance Abuse and Mental Health Services Administration's (SAMHSA) website. This generated a potential sample size of 824 APRNs, all of whom were sent email solicitations to complete a Qualtrics survey. After 3 weeks, 55 surveys were completed, and the data were analyzed. Descriptive statistics were generated as well as a logistic regression with five potential predictor variables against the outcome variable (defined as use of naltrexone for AUD patients).

RESULTS

Years practicing as an APRN was found to negatively predict naltrexone prescribing behavior for AUD patients. Practice setting and work experience with an addiction specialist physician were not found to predict naltrexone prescribing behavior for AUD patients.

CONCLUSION

Implications for further study were discussed, with emphasis on regulatory variance between states.

Assessing Naltrexone Prescribing and Barriers to Initiation for Alcohol Use Disorder: A Multidisciplinary, Multisite Survey

OBJECTIVE

To survey barriers in prescribing naltrexone for alcohol use disorder.

METHODS

A 12-question survey related to naltrexone prescribing patterns, perceptions, and knowledge was sent to 770 prescribers in the departments of internal medicine, family medicine, and psychiatry across a health system with sites in Arizona, Florida, and Minnesota.

RESULTS

Responses were obtained and included for 146/770 prescribers (19.0% response rate). Most respondents were in the department of internal medicine (n = 94, 64.4%), but the departments of psychiatry (n = 22, 15.1%) and family medicine (n = 30, 20.5%) were also represented. Only 34 (23.3%) respondents indicated they had prescribed naltrexone in the previous 3 months. The most common reasons for not prescribing naltrexone were "unfamiliarity with naltrexone for treatment of alcohol use disorder" and "patients do not have appropriate follow-up or are not in a formal treatment program." Compared with those representing internal/family medicine, psychiatry respondents were more likely to prescribe naltrexone and answer knowledge questions correctly.

CONCLUSION

In this survey among primarily non-addiction-trained prescribers, a disparity was shown for prescribing naltrexone and in knowledge barriers between staff in internal/family medicine and psychiatry. There exist opportunities for education and quality improvement that promote the prescribing of naltrexone for alcohol use disorder by non-addiction specialists.

The correlates and extent of prescribing of medications for alcohol relapse prevention in England

AIMS

To determine the pattern and extent of prescribing of medications for alcohol relapse prevention (ARP) in England.

DESIGN

Cross-sectional.

SETTING

Specialist drug and alcohol treatment providers in England reporting to the National Drug Treatment Monitoring System.

PARTICIPANTS

Service users aged 18+, with alcohol the primary substance of dependence, completing a treatment journey between April 2013 and March 2016 (n = 188 152).

MEASUREMENTS

Prescription of medications for ARP during a treatment journey. Data on service users' demographics, treatment and clinical characteristics were extracted.

FINDINGS

The rate of prescribing medications for ARP was 2.1% in 2013/14, 6.8% in 2014/15 and 7.8% in 2015/16. A greater likelihood of prescription was associated with treatment journey year [2014/15; adjusted odds ratio (aOR) = 3.269, 95% confidence intervals (CI) = 3.044-3.510, 2015/16; aOR = 3.823, CI = 3.560-4.106], age (25-34; aOR = 1.622, CI = 1.380-1.907, 35-54; aOR = 1.901, CI = 1.628-2.220 or 55+; aOR = 1.700, CI = 1.446-1.999), female gender (aOR = 1.129, CI = 1.077-1.184), white ethnicity (aOR = 1.219, CI = 1.077-1.380), regional prevalence of alcohol dependence (middle rate; aOR = 1.121, CI = 1.024-1.228), severity of alcohol dependence (moderate dependence without complex needs; aOR = 1.329, CI = 1.244-1.419, severe dependence without complex needs; aOR = 1.308, CI = 1.188-1.441, moderate/severe dependence with complex needs; aOR = 1.131, CI = 1.020-1.255), treatment setting (inpatient; aOR = 10.512, CI = 9.950-11.104, primary care; aOR = 2.264, CI = 2.050-2.500, residential; aOR = 3.216, CI = 2.807-3.685), prior treatment for alcohol dependence (aOR = 1.242, CI = 1.183-1.304), longer treatment journey (aOR = 1.002, CI = 1.002-1.002), more drinking days in the prior 28 days (aOR = 1.021, CI = 1.018-1.024) and drinking a higher number of alcohol units in the prior 28 days (aOR = 1.002 CI = 1.001-1.004). Living in a region of England with the lowest alcohol prevalence was associated with a lower likelihood of prescription of medication for aRP (AOR = 0.491, CI = 0.436-0.552).

CONCLUSIONS

In England, medications for alcohol relapse prevention are rarely prescribed (e.g. 7.8% in 2015/16) and those prescriptions appear to be associated with specific service user demographics, treatment and clinical characteristics.

First-line Medications for the Outpatient Treatment of Alcohol Use Disorder: A Systematic Review of Perceived Barriers

OBJECTIVES

Alcohol use disorder (AUD) is a common illness with significant health and economic consequences. Although three pharmacotherapeutic agents have been shown to decrease heavy drinking days among individuals with AUD, they are vastly underutilized in clinical practice. The objective of this review was to elucidate barriers that may prevent patients from obtaining medication for addiction treatment (MAT) for AUD in an outpatient or residential setting.

METHODS

Electronic searches of Medline and EMBASE were conducted, and reference lists were hand-searched. All study designs which discussed the use of MAT for AUD in an outpatient or residential setting were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible articles, the full texts of which were retrieved and assessed for inclusion.

RESULTS

After eliminating duplicate citations and articles that did not meet eligibility criteria, 23 articles were included in the review. Perceived barriers to obtaining pharmacotherapy for the treatment of AUD in an outpatient or residential setting were grouped into 3 themes: lack of knowledge and concerns about efficacy and complexity of prescribing; treatment philosophy and stigma; medication accessibility including formulary restrictions, geographical and socioeconomic barriers.

CONCLUSIONS

Although evidence-based pharmacotherapeutics have been approved for the treatment of AUD, our findings suggest patients continue to experience barriers to the use of these medications. Efforts should be made to increase rates of prescribing by providers and the use of medications by patients. More research is needed to further elucidate perceived barriers to MAT use, along with strategies to overcome them.

Organizational Capacity and Readiness to Provide Medication for Individuals with Co-Occurring Alcohol Use Disorders in Public Mental Health Settings

Alcohol use disorders (AUD) in individuals with mental illness are largely untreated. The purpose of this study was to identify gaps in organizational capacity and readiness to provide medications for AUD in outpatient public mental health clinics. We selected a purposive sample of eight publicly funded outpatient mental health clinics operated by the Los Angeles County Department of Mental Health; clinics were chosen to maximize heterogeneity. Guided by theories of organizational capacity and readiness and research on the adoption of pharmacotherapy for AUD in primary and specialty care treatment settings, we conducted semi-structured interviews and focus groups with administrators, providers and staff, and a qualitative analysis of the results. Respondents described significant organizational capacity and behavioral readiness constraints to providing medication treatment for AUD. Both groups articulated a perception that mental health clinics were not designed to provide co-occurring AUD treatment because of large caseloads, staffing configurations, and time constraints that did not support the delivery of appropriate treatment, and a lack of protocols and workflow procedures. We documented organizational capacity and readiness constraints which impede the delivery of medication treatment for AUD in a large mental helth system. While some constraints have straightforward solutions, others require structural changes to the way care is delivered, and state-level funding and policy changes.

Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA

Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.

Effects of Global Payment and Accountable Care on Medication Treatment for Alcohol and Opioid Use Disorders

OBJECTIVES

The Alternative Quality Contract (AQC) implemented in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) is intended to improve quality and control costs by putting providers at risk for total medical spending and tying payment to performance on specified quality measures. We examined the AQC's early effects on use of and spending on medication treatment (MT) for addiction among individuals with alcohol use disorders (AUDs) and opioid use disorders (OUDs), conditions not subject to any performance measurement in the AQC.

METHODS

Using data from 2006 to 2011, we use difference-in-difference estimation of the effect of the AQC on MT using a comparison group of enrollees in BCBSMA whose providers did not participate in the AQC. We compared AQC and non-AQC enrollees with AUDs (n = 37,113 person-years) and/or OUDs (n = 12,727 person-years) on any use of MT, number of prescriptions filled, and MT spending adjusting for demographic and health status characteristics.

RESULTS

There was no difference in MT use among AQC enrollees with OUD (38.7%) relative to the comparison group (39.1%) (adjusted difference = -0.4%, 95% confidence interval -3.8% to 3.0%, P = 0.82). Likewise, there was no difference in MT use for AUD between the AQC (6.3%) and comparison group (6.5%) (P = 0.64). Similarly, we detected no differences in number of prescriptions or spending.

CONCLUSIONS

Despite incentives for improved integration and quality of care under a global payment contract, the initial 3 years of the AQC showed no impact on MT use for AUD or OUD among privately insured enrollees with behavioral health benefits.

Acceptability of pharmacotherapy for hazardous alcohol use among men who have sex with men: Findings from a qualitative study

INTRODUCTION

Men who have sex with men (MSM) experience high rates of binge drinking, alcohol use disorder (AUD), and alcohol-related health issues. Pharmacotherapy for AUD can reduce hazardous drinking, yet remains underutilized among MSM. This qualitative study examined knowledge and perceptions regarding AUD medications among MSM, with an emphasis on naltrexone.

METHODS

Three focus group discussions (FGDs) with MSM who consumed alcohol in the past year were conducted in February 2015 (N = 39) in the San Francisco Bay Area. The FGD guide generated discussions about hazardous drinking, the social contexts of drinking, and alcohol reduction and cessation options, including pharmacotherapy. Interviews were analyzed via directed content analysis to codify themes.

RESULTS

For participants, drinking at LGBTQ bars was an important social activity. Many expressed interest in reducing alcohol use, but few had heard of pharmacotherapy for AUD. Potential uptake was limited by perceptions of disulfiram as the prototype medication, side effects associated with disulfiram, and concerns that medications do not address alcohol-related stigma or social drivers of drinking. Participants were more receptive to pharmacotherapy when presented with medication options that did not require abstinence. Participants reported being more likely to try pharmacotherapy as part of a peer group or treatment program.

CONCLUSIONS

Efforts to increase the knowledge and availability of naltrexone and harm reduction approaches, while addressing addiction- and medication-related stigma, might improve pharmacotherapy uptake for AUD and decrease hazardous drinking among MSM for whom alcohol holds social significance.

Knowledge, past use, and willingness to start medication-assisted treatment among persons undergoing alcohol detoxification

BACKGROUND/OBJECTIVES

The current study examined knowledge of previous use, and willingness to take alcohol-related medication among individuals in medically supervised detoxification.

METHODS

Participants (n = 302) provided health and demographic information, substance use and detoxification history, PCP visits, and AA attendance.

RESULTS

Most patients had knowledge of alcohol medications, one-third had past prescription, and over 80% reported willingness to take medication. Previous detoxification predicted medication knowledge, while previous treatment predicted past prescription.

DISCUSSION/CONCLUSIONS

More patients are willing to take medication than are prescribed medication.

SCIENTIFIC SIGNIFICANCE

Findings suggest the opportunity to increase medication use following detoxification which could reduce subsequent relapse. (Am J Addict 2017;26:118-121).

Nalmefene for the management of alcohol dependence: review on its pharmacology, mechanism of action and meta-analysis on its clinical efficacy

Nalmefene, a mu- and delta-opioid receptor (MOR, DOR) antagonist and a partial kappa-opioid receptor (KOR) agonist, is approved in the European Union and other countries for the reduction of alcohol consumption in alcohol dependent patients with a high drinking risk level according to WHO ("target population"). This review presents an overview of nalmefene׳s pharmacology, its mechanisms of action and a meta-analysis on its efficacy in reducing alcohol consumption. The review was based on a systematic search of the literature. Random effects meta-analyses were performed on published and unpublished trials directed at drinking reduction using the changes in heavy drinking days (HDDs) and daily total alcohol consumption (TAC) from baseline to the primary endpoint. For each included study and each dose, Hedges' g was used as an unbiased estimator of the standardised mean differences between nalmefene and placebo. Preclinical data suggests that nalmefene counters alcohol-induced dysregulations of the MOR/endorphine and the KOR/dynorphin system. Evidence further suggests that reduced alcohol consumption is an effective treatment strategy that appeals to patients not ready for abstinence. Finally, meta-analyses confirmed the efficacy of 20mg nalmefene for reducing HDDs in the ITT population (Hedge׳s g=-0.20; 95% CI -0.30 to -0.09) and the target population (Hedge׳s g=-0.33; 95% CI -0.48 to -0.18). Similar results were seen for TAC. Several meta-analyses, including this new meta-analysis, support nalmefene׳s efficacy in reducing alcohol consumption. In conclusion, because it does not require abstinence, this treatment has the potential to motivate more patients for treatment and thus helps to address a major public health concern.

Organizational Predictors of Pharmacological Innovation Adoption: The Case of Disulfiram

The research-to-practice gap in substance abuse treatment, particularly with regard to pharmacological innovations, necessitates the consideration of organizational characteristics that facilitate the adoption of innovations. Using data from a nationally representative sample of 394 privately funded substance abuse treatment centers, this study examines variation in the adoption of disulfiram in terms of organizational structure, workforce professionalism, and treatment philosophy. Logistic regression results indicated that hospital-based centers were significantly more likely to use disulfiram than freestanding treatment programs. In addition, the percentage of counselors with master's degrees and the percentage of certified/licensed counselors were positively associated with the likelihood of disulfiram utilization. Treatment centers that emphasized confrontational group therapy and spirituality were less likely to use disulfiram, while the adoption of disulfiram was more likely in centers that emphasized a medical model of addiction.

Clinicians' Beliefs and Awareness of Substance Abuse Treatments in Research- and Nonresearch-Affiliated Programs

Clinicians' beliefs and awareness of treatment techniques may influence what innovations are perceived as needed and adoption of them. Clinicians at research-affiliated programs, however, may differ from clinicians at programs without research affiliation. We surveyed 162 clinicians at 15 substance abuse treatment programs (five research-affiliated programs and 10 matched nonresearch-affiliated programs) on addiction treatment belief items and awareness of Clinical Trials Network treatment innovations currently being tested. The research-affiliated clinicians had a higher percentage of clinicians with advanced degrees. In bivariate analyses, three differences in beliefs and four differences in awareness by research affiliation were found. Most of these differences disappeared during multivariate analyses. The results suggest that beliefs and awareness toward addiction treatment of research-affiliated clinicians, when controlling for demographic and professional characteristics, may be similar to those of other clinicians. This similarity should help in wider dissemination for those innovations found acceptable to clinicians at research-affiliated programs.

Discovery, Development, and Adoption of Medications to Treat Alcohol Use Disorder: Goals for the Phases of Medications Development

For more than 25 years, advances have been made in developing medications to treat alcohol use disorder (AUD), highlighted by the U.S. Food and Drug Administration's approval of naltrexone (oral and long-acting) and acamprosate. Despite this progress, more work remains to be done in this area because these medications, although effective for some people, do not work for everyone. A high priority for the National Institute on Alcohol Abuse and Alcohol is to put into place a solid infrastructure to aid in the development of medications that are more effective than those currently available and with few side effects. Medication development, especially for a disorder as complex as AUD, is challenging and involves multiple phases, including discovery of "druggable" targets, preclinical studies, human clinical trials, and the adoption and implementation of the new medication into mainstream medicine. A successful medications development program requires clearly established goals for each phase to ensure that a candidate compound is not trapped in one particular phase, a condition known as "the valley of death." In this article, the phases of medication development are described as they apply to AUD, and specific goals of each phase are identified for the next decade. In addition, several important crosscutting themes are outlined for each phase, all of which are essential for advancing medications development. These include identifying and validating screening models and druggable targets, making use of precision medicine, and establishing partnerships among key stakeholders. Our goal in writing this article is to provide a guide on medications development that will aid the alcohol research community in planning, testing, and developing medications for AUD.

Rural substance use treatment centers in the United States: an assessment of treatment quality by location

BACKGROUND

While previous research has added to the understanding of rural residents' unique health challenges, much remains to be learned about the provision of substance use disorder (SUD) treatment in rural areas. A key question is difference in structural resources and quality of care between rural and urban treatment centers.

OBJECTIVE

To examine differences in treatment quality in rural and urban centers and to determine if differences in treatment quality are contextualized by centers' structural resources.

METHODS

Utilizing combined data from two representative samples of SUD treatment centers (n = 591), we used a series of multivariate regressions to analyze the association between center rurality and various indicators of structural characteristics and treatment quality. Interaction effects were further examined between structural characteristics and treatment quality indicators.

RESULTS

We found that structural and quality differences between rural and urban treatment centers were present. Rural centers had reduced access to highly educated counselors, were more likely to be non-profit and dependent on public funding, offered fewer wraparound services, and had less diverse specialized treatment options. Our results also indicated that rural centers were less likely to prescribe buprenorphine as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Rural center access to a physician contextualized the association between center rurality and the more limited provision of wraparound services.

CONCLUSION

Our findings suggest that treatment quality differs between urban and rural centers in complex ways that are subject to resource availability.

Counselor training and attitudes toward pharmacotherapies for opioid use disorder

BACKGROUND

Methadone and buprenorphine have been demonstrated to be effective in the treatment of opioid use disorder (OUD), especially when combined with psychosocial treatment. Despite buprenorphine's association with fewer withdrawal symptoms and lessened risk of abuse, compared with methadone, its adoption remains limited. Given the vital role that counselors may play in its successful implementation, their knowledge and perceptions of opioid agonist therapy may be facilitators or barriers to its acceptance.

METHODS

Informed by diffusion theory, the current study examined perceptions of buprenorphine's and methadone's acceptability among 725 counselors employed in a nationally representative sample of substance use disorder treatment centers. First, we provided descriptive statistics about medication diffusion, extent of training received about the medications, and perceptions of acceptability of each medication. Then, we compared acceptability of opioid agonists with other treatment approaches for OUD. Finally, we conducted 2 ordinary least squares regressions to examine counselor acceptability of buprenorphine and of methadone.

RESULTS

Descriptive statistics suggested that diffusion of information about buprenorphine and methadone was not complete, and training was not extensive for either medication. Counselors reported greater acceptability and training of buprenorphine compared with methadone. Methadone was rated as the least acceptable among all other treatment approaches. Multivariate analyses indicated regional differences, and that medication-specific training, adaptability, and educational attainment were positively related with perceptions of acceptability of either medication, even after controlling for organizational characteristics. Adherence to a 12-step orientation was negatively associated with acceptability.

CONCLUSIONS

Dissemination of information about opioid agonist therapy is occurring. Nevertheless, the fact that 20% of counselors admitted not knowing enough about either buprenorphine's or methadone's effectiveness is surprising in light of the extensive literature documenting their effectiveness. Future research should focus upon different types of training that can inform physicians, counselors, and patients about the use of opioid agonist therapy.

Factors associated with willingness to take extended release naltrexone among injection drug users

BACKGROUND

Although opioid-agonist therapy with methadone or buprenorphine/naloxone is currently the mainstay of medical treatment for opioid use disorder, these medications often are not well accepted or tolerated by patients. Recently, extended release naltrexone (XR-NTX), an opioid antagonist, has been advanced as an alternative treatment. The willingness of opioid-addicted patients to take XR-NTX has not been well described.

METHODS

Opioid-using persons enrolled in a community-recruited cohort in Vancouver, Canada, were asked whether or not they would be willing to take XR-NTX. Logistic regression was used to independently identify factors associated with willingness to take the medication.

RESULTS

Among the 657 participants surveyed between June 1, 2013, and November 30, 2013, 342 (52.1%) were willing to take XR-NTX. One factor positively associated with willingness was daily heroin injection (adjusted odds ratio [AOR] = 1.53; 95% confidence interval [CI] = 1.02-2.31), whereas Caucasian ethnicity was negatively associated (AOR = 0.59; 95% CI = 0.43-0.82). Satisfaction with agonist therapy (13.4%) and unwillingness to stop opioids being used for pain (26.9%) were the most common reasons for being unwilling to take XR-NTX.

CONCLUSIONS

A high level of willingness to take XR-NTX was observed in this setting. Interestingly, daily injection heroin use was positively associated with willingness, whereas Caucasian participants were less willing to take XR-NTX. Although explanations for unwillingness were described in this study, further research is needed to investigate real-world acceptability of XR-NTX as an additional option for the treatment of opioid use disorder.

Service delivery and pharmacotherapy for alcohol use disorder in the era of health reform: Data from a national sample of treatment organizations

BACKGROUND

Although there is a growing literature examining organizational characteristics and medication adoption, little is known about service delivery differences between specialty treatment organizations that have and have not adopted pharmacotherapy for alcohol use disorder (AUD). This study compares adopters and nonadopters across a range of treatment services, including levels of care, availability of tailored services for specific populations, treatment philosophy and counseling orientations, and adoption of comprehensive wraparound services.

METHODS

In-person interviews were conducted with program leaders from a national sample of 372 organizations that deliver AUD treatment services in the United States.

RESULTS

About 23.6% of organizations had adopted at least 1 AUD medication. Organizations offering pharmacotherapy were similar to nonadopters across many measures of levels of care, tailored services, treatment philosophy, and social services. The primary area of difference between the 2 groups was for services related to health problems other than AUD. Pharmacotherapy adopters were more likely to offer primary medical care, medications for smoking cessation, and services to address co-occurring psychiatric conditions.

CONCLUSIONS

Service delivery differences were modest between adopters and nonadopters of AUD pharmacotherapy, with the exception of health-related services. However, the greater adoption of health-related services by organizations offering AUD pharmacotherapy represents greater medicalization of treatment, which may mean these programs are more strongly positioned to respond to opportunities for integration under health reform.

The role of expectation in the therapeutic outcomes of alcohol and drug addiction treatments

Throughout history, patient-physician relationships have been acknowledged as an important component of the therapeutic effects of any pharmacological treatment. Here, we discuss the role of physicians' expectations in influencing the therapeutic outcomes of alcohol and drug addiction pharmacological treatments. As largely demonstrated, such expectations and attitudes may contribute to produce placebo and nocebo effects that in turn affect the course of the disease and the response to the therapy. This article is aimed at discussing the current insights into expectations, placebo and nocebo mechanisms and their impact on the therapeutic outcomes of alcohol and drug addiction treatments; with the goal of informing physicians and other health care providers about the potentially widespread implications for clinical practice and for a successful treatment regimen.

Views about responsibility for alcohol addiction and negative evaluations of naltrexone

BACKGROUND

Moral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors' attitudes on these questions. Meanwhile, a separate literature has investigated counselors' negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor's views of individual responsibility for alcohol addiction are related to that counselor's views of naltrexone.

METHODS

Using a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor's views about individual responsibility for alcohol addiction and using naltrexone to treat it.

RESULTS

We find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone's side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person's motivation to recover. Combined views of greater responsibility for addiction's onset and recovery also significantly predicted stronger agreement with objections.

CONCLUSIONS

We conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.

Pharmacotherapy for alcohol use disorder: current and emerging therapies

Alcohol use disorder is a heterogeneous illness with a complex biology that is controlled by many genes and gene-by-environment interactions. Several efficacious, evidence-based treatments currently exist for treating and managing alcohol use disorder, including a number of pharmacotherapies that target specific aspects of biology that initiate and maintain dangerous alcohol misuse. This article reviews the neurobiological and neurobehavioral foundation of alcohol use disorder, the mechanisms of action and evidence for the efficacy of currently approved medications for treatment, and the literature on other emerging pharmacotherapies.

A qualitative study of the adoption of buprenorphine for opioid addiction treatment

Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients' and other clinicians' experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments.

The case for chronic disease management for addiction

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Research opportunities for medications to treat alcohol dependence: addressing stakeholders' needs

During the past decade, significant advances have been made in the development of medications to treat alcohol dependence. Four medications have been approved by the U.S. Food and Drug Administration for treating alcohol dependence-naltrexone, injectable naltrexone, acamprosate, and disulfiram-and several others show promise. The fact remains, however, that because of the heterogeneity of alcohol dependence, these medications will not work for all people, in all circumstances. Moreover, clinicians are not routinely prescribing these medications for alcohol treatment. This commentary poses a number of issues that must be addressed in order to advance the alcohol research field and to make medications a mainstream treatment for problematic drinking. These issues are framed from the perspective of the various stakeholders involved, including clinicians, patients, regulatory agencies, the pharmaceutical industry, and third-party payers. Addressing these issues will not only help to improve treatment but, as further described, will also open up many new research opportunities for alcohol investigators in the coming decade.

Factors determining how early adopter physicians use buprenorphine in treatment

Since October 2002, physicians have been able to prescribe buprenorphine to treat opiate dependence. We examined how physicians who prescribe buprenorphine are using it in practice to determine how well buprenorphine has been adopted as a realistic and effective treatment option, with the ultimate goal of improved access to opiate addiction treatment. Most prescribing physicians offer buprenorphine in various ways, ranging from detoxification to extended maintenance, including transfer from methadone and treatment of chronic pain. On average, physicians write 16 prescriptions monthly, one-third of which are for new patients. The average buprenorphine prescriber has treated 72 buprenorphine patients to date. Two-thirds prescribe for both detoxification and maintenance, allowing flexibility to meet patient needs; 19% prescribe only for detoxification, and 14% only for maintenance. Prescribing patterns are associated with experience treating addictions, patient mix, and available resources. Physicians who prescribe for detoxification only should recognize that additional resources are not necessary for maintenance, the recommended treatment for opiate addiction. Physicians who prescribe for maintenance only would benefit from linkages with physicians or facilities that offer buprenorphine detoxification, so patients who refuse maintenance may still be treated. With additional network development and support for physicians, access to buprenorphine treatment can be improved.

Medications development to treat alcohol dependence: a vision for the next decade

More than 76 million people world-wide are estimated to have diagnosable alcohol use disorders (AUDs) (alcohol abuse or dependence), making these disorders a major global health problem. Pharmacotherapy offers promising means for treating AUDs, and significant progress has been made in the past 20 years. The US Food and Drug Administration approved three of the four medications for alcoholism in the last two decades. Unfortunately, these medications do not work for everyone, prompting the need for a personalized approach to optimize clinical benefit or more efficacious medications that can treat a wider range of patients, or both. To promote global health, the potential reorganization of the National Institutes of Health (NIH) must continue to support the National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) vision of ensuring the development and delivery of new and more efficacious medications to treat AUDs in the coming decade. To achieve this objective, the NIAAA Medications Development Team has identified three fundamental long-range goals: (1) to make the drug development process more efficient; (2) to identify more efficacious medications, personalize treatment approaches, or both; and (3) to facilitate the implementation and adaptation of medications in real-world treatment settings. These goals will be carried out through seven key objectives. This paper describes those objectives in terms of rationale and strategy. Successful implementation of these objectives will result in the development of more efficacious and safe medications, provide a greater selection of therapy options and ultimately lessen the impact of this devastating disorder.

Physicians in the substance abuse treatment workforce: understanding their employment within publicly funded treatment organizations

The employment of physicians by substance abuse treatment organizations is understudied, despite physicians' importance in implementing pharmacotherapy and integrating treatment into the broader system of medical care. Drawing on data collected from 249 publicly funded treatment organizations, this study examined organizational and environmental factors associated with the employment of physicians in these settings. A negative binomial regression model indicated that greater numbers of physicians were employed when organizations offered detoxification services, were embedded in health care settings, and were larger in size. Funding barriers, including the costs of physicians and inadequate reimbursement by funders, were negatively associated with physician employment. Programs unaware that they could use state contract funding to pay for medical staff employed fewer numbers of physicians than programs aware of this type of state policy. Attempts to increase physician employment in substance abuse treatment may require attention to both organizational and environmental factors rather than simply trying to attract individuals to the field. Increasing physician employment may be challenging in the current economic climate.

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

Barriers to implementing evidence-based practices in addiction treatment programs: comparing staff reports on Motivational Interviewing, Adolescent Community Reinforcement Approach, Assertive Community Treatment, and Cognitive-behavioral Therapy

PURPOSE

This qualitative study explored barriers to implementing evidence-based practices (EBPs) in community-based addiction treatment organizations (CBOs) by comparing staff descriptions of barriers for four EBPs: Motivational Interviewing (MI), Adolescent Community Reinforcement Approach (A-CRA), Assertive Community Treatment (ACT), and Cognitive-behavioral Therapy (CBT).

METHODS

The CBOs received CSAT/SAMHSA funding from 2003 to 2008 to deliver services using EBPs. Phone interview responses from 172 CBO staff directly involved in EBP implementation were analyzed using content analysis, a method for making inferences and developing themes from the systematic review of participant narratives (Berelson, 1952).

RESULTS

Staff described different types of barriers to implementing each EBP. For MI, the majority of barriers involved staff resistance or organizational setting. For A-CRA, the majority of barriers involved specific characteristics of the EBP or client resistance. For CBT, the majority of barriers were associated with client resistance, and for ACT, the majority of barriers were associated with resources.

DISCUSSION

EBP designers, policy makers who support EBP dissemination and funders should include explicit strategies to address such barriers. Addiction programs proposing to use specific EBPs must consider whether their programs have the organizational capacity and community capacity to meet the demands of the EBP selected.

Employing policy and purchasing levers to increase the use of evidence-based practices in community-based substance abuse treatment settings: reports from single state authorities

State public health authorities are critical to the successful implementation of science based addiction treatment practices by community-based providers. The literature to date, however, lacks examples of state level policy strategies that promote evidence-based practices (EBPs). This mixed-methods study documents changes in two critical state-to-provider strategies aimed at accelerating use of evidence-based practices: purchasing levers (financial incentives and mechanisms) and policy or regulatory levers. A sample of 51 state representatives was interviewed. Single State Authorities for substance abuse treatment (SSAs) that fund providers directly or through managed care were significantly more likely to have contracts that required or encouraged evidence-based interventions, as compared to SSAs that fund providers indirectly through sub-state entities. Policy levers included EBP-related legislation, language in rules and regulations, and evidence-based criteria in state plans and standards. These differences in state policy are likely to result in significant state level variations regarding both the extent to which EBPs are implemented by community-based treatment providers and the quality of implementation.

Barriers to use of pharmacotherapy for addiction disorders and how to overcome them

Substance use disorders are highly prevalent, debilitating conditions for which effective pharmacotherapies exist with a broad evidence base, yet pharmacotherapy for the treatment of addiction disorders is underutilized. The goals of this review are to describe the barriers that may contribute to poor adoption and utilization of pharmacotherapy for alcohol and opioid dependence at the system, provider, and patient level and to discuss ways to overcome those barriers. Multifaceted efforts directed at all three levels may be needed to speed pharmacotherapy adoption. More research is needed to help us better understand barriers from patients' perspectives. Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the practice, system, and individual patients. Pharmacotherapy is a valuable tool in the clinical armamentarium of addiction treatment; thus, overcoming barriers to implementation may improve clinical and social outcomes.

The substance abuse counseling workforce: education, preparation, and certification

The National Drug Abuse Treatment Clinical Trials Network (CTN) is an alliance of drug abuse treatment programs and research centers testing new interventions and implementation factors for treating alcohol and drug use disorders. A workforce survey distributed to those providing direct services in 295 treatment units in the CTN obtained responses from 1750 individuals with a job title of counselor (n = 1395) or counselor supervisor (n = 355). A secondary analysis compares and describes both groups. Supervisors were more likely to be licensed or certified. Master's degrees were more common among counselors in outpatient and methadone programs. Counselors in residential settings tended to be on the job fewer years. Finally, higher education was associated with greater familiarity with and acceptance of evidence-based practices.

Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations

OBJECTIVES

Publicly funded addiction treatment organizations have been slow to adopt pharmacotherapies. Few studies have examined the organizational factors associated with adoption of different types of medication in this treatment sector. This study identifies organization-level facilitators and barriers to the use of medications in publicly funded addiction treatment organizations.

METHODS

Face-to-face interviews with a sample of 318 administrators of a representative sample of publicly funded addiction treatment centers in the US.

RESULTS

Only 23.4% of programs reported using any of the five FDA-approved pharmacotherapies for treating addiction. An additional 14.3% of programs only used medications approved for the treatment of psychiatric disorders. Multivariate multinomial logistic regression results revealed that the odds of adoption of addiction pharmacotherapies were significantly greater in government-owned programs and in programs with more medical personnel. Programs that relied more heavily on non-Medicaid public funding tended to be less likely to adopt addiction treatment medications. Greater contact with pharmaceutical representatives was positively associated with medication adoption.

CONCLUSIONS

Current public funding policies and lack of access to medical personnel are barriers to the adoption of medications by publicly funded addiction treatment organizations. Efforts to promote adoption may also benefit from greater detailing activities by pharmaceutical representatives. These findings suggest that the large research investment devoted to developing addiction treatment medications may have limited public health impact due to the characteristics of publicly funded service delivery system as well as the limited attention given to this system by commercial purveyors of medications.

Adoption and implementation of medications in addiction treatment programs

OBJECTIVES

Little is known about the extent to which medications are being implemented as routine care in addiction treatment programs. This research describes medication adoption and implementation within the privately funded treatment sector.

METHODS

Face-to-face interviews were conducted with 345 administrators of a nationally representative sample of privately funded substance treatment organizations in the United States.

RESULTS

Rates of adoption of addiction treatment medications in private sector programs were lower than the adoption of psychiatric medications. Even when analyses were restricted to programs with access to physicians, adoption of each addiction treatment medication had occurred in less than 50% of programs. Within adopting programs, implementation was highly variable. While about 70% of patients with co-occurring psychiatric diagnoses received psychiatric medications, rates of implementation of medication-assisted treatment for opioid dependence and alcohol use disorders were just 34.4% and 24.0%, respectively.

CONCLUSIONS

Although previous research has documented higher rates of medication adoption in privately funded treatment programs, this study revealed that both adoption and implementation of pharmacotherapies to treat addiction remains modest. Future research should examine the different types of barriers to implementation, such as physician decision-making, patient preferences, and system-level barriers stemming from financing and public policy.

Counselor attitudes toward the use of naltrexone in substance abuse treatment: a multi-level modeling approach

Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselor's attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.

Efficacy of extended-release naltrexone in patients with relatively higher severity of alcohol dependence

BACKGROUND

Because some literature reviews have suggested that naltrexone's benefit may be limited to less-severe alcohol dependence, and exclusively to reduction in heavy drinking rather than abstinence, we examined the efficacy of once per month, injectable extended-release naltrexone (XR-NTX 380 mg) in patients with relatively higher severity alcohol dependence.

METHODS

Post hoc analyses examined data from a multicenter, placebo-controlled, 24-week randomized trial of XR-NTX for alcohol dependence (N = 624). We analyzed treatment effects in alcohol-dependent patients who had higher baseline severity, as measured by: (i) the Alcohol Dependence Scale (ADS) or (ii) having been medically detoxified in the week before randomization. Efficacy was also examined via the relationship between pretreatment severity indices and reporting at least 4 days of lead-in abstinence prior to treatment-a major predictor of good outcome in the original study.

RESULTS

Higher severity alcohol-dependent patients, defined by the ADS, when receiving XR-NTX 380 mg (n = 50) compared with placebo (n = 47), had significantly fewer heavy-drinking days in-trial (hazard ratio=0.583; p = 0.0049) and showed an average reduction of 37.3% in heavy-drinking days compared with 27.4% for placebo-treated patients (p = 0.039). Among those who had a detoxification just prior to randomization, these reductions were 48.9% (XR-NTX 380 mg; n = 11) and 30.9% (placebo; n = 15) (p = 0.004). Subjects with at least 4 days of pretreatment abstinence (n = 82) versus those without (n = 542) had significantly higher pretreatment ADS scores (p = 0.002) and were more likely to require detoxification prior to randomization (p < 0.001). Patients with lead-in abstinence experienced significantly better maintenance of initial and 6-month abstinence.

CONCLUSIONS

These secondary analyses support the efficacy of XR-NTX 380 mg in relatively higher severity alcohol dependence for both reduction in heavy drinking and maintenance of abstinence, with implications for the role of adherence pharmacotherapy.

Addressing the HIV-related needs of substance misusers in New York State: the benefits and barriers to implementing a "one-stop shopping" model

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs) are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.

Differences in Substance Abuse Counselors' Knowledge of Tobacco Cessation Medication Effectiveness: 2002-2008

Counselors play a supportive role in patients' substance abuse treatment, including tobacco cessation. Thus, counselors should be knowledgeable about tobacco cessation medications (TCMs). This study examined differences in counselors' knowledge of and familiarity with (i.e., diffusion) bupropion and nicotine replacement therapy (NRT) between 2002 and 2008 and identified predictors of diffusion. Repeated cross-sectional questionnaire data were obtained in 2002/04 from 992 counselors and in 2007/08 from 1,226 counselors working in private treatment programs. Results indicated that more counselors in 2007/08 did not know about bupropion to rate its effectiveness than in 2002/04; no differences were found for NRT. Among both samples of counselors who were familiar with TCMs, effectiveness was rated higher in 2007/08 than in 2002/04. Findings suggest that educated and trained counselors are important in diffusing TCMs. Knowledgeable counselors may be able to educate patients interested in tobacco cessation about available treatments and encourage compliance with TCMs.

Evidence-based practices in addiction treatment: review and recommendations for public policy

The movement in recent years towards evidence-based practice (EBP) in health care systems and policy has permeated the substance abuse treatment system, leading to a growing number of federal and statewide initiatives to mandate EBP implementation. Nevertheless, due to a lack of consensus in the addiction field regarding procedures or criteria to identify EBPs, the optimal processes for disseminating empirically based interventions into real-world clinical settings have not been identified. Although working lists of interventions considered to be evidence-based have been developed by a number of constituencies advocating EBP dissemination in addiction treatment settings, the use of EBP lists to form policy-driven mandates has been controversial. This article examines the concept of EBP, critically reviews criteria used to evaluate the evidence basis of interventions, and highlights the manner in which such criteria have been applied in the addictions field. Controversies regarding EBP implementation policies and practices in addiction treatment are described, and suggestions are made to shift the focus of dissemination efforts from manualized psychosocial interventions to specific skill sets that are broadly applicable and easily learned by clinicians. Organizational and workforce barriers to EBP implementation are delineated, with corresponding recommendations to facilitate successful dissemination of evidence-based skills.

Adoption of medications in substance abuse treatment: priorities and strategies of single state authorities

Research has confirmed the effectiveness of medications, when used in conjunction with ongoing counseling, to treat substance abuse disorders. This article describes a national, mixed-methods research project designed to investigate single state authorities' (SSAs) perceptions of adoption of evidence-based practices in substance abuse treatment. Results are focused specifically on medication-assisted treatment, one of five evidence-based practices defined by the National Quality Forum. Medication-assisted treatment (MAT) is an important and effective part of comprehensive care options available to clients who are chronically ill with alcohol and other drug disorders. Despite mounting clinical evidence and increased availability, overall rates of implementation and sustained adoption of medications to treat addiction remain limited. The results illustrate that the SSA representatives who fund public treatment programs believe MAT is a priority and worthy of system-wide implementation. Current strategies utilized by SSAs to support the adoption of MAT are detailed, as are barriers to adoption and implementation.