Understanding attitudes towards use of medication in substance abuse treatment: A multilevel approach

Attitudes toward opioid use disorder pharmacotherapy among recovery community center attendees

BACKGROUND

Despite their proven efficacy, medications for opioid use disorder (MOUD) are underutilized. Negative beliefs and attitudes toward MOUD are quite common, yet rapidly expanding recovery community centers (RCCs) may offer a promising venue for fostering MOUD support as they operate under the maxim, "many pathways [to recovery], all should be celebrated" and are utilized mainly by those with opioid use disorder. The current study provides a first look at MOUD attitudes and their correlates in RCC attendees.

METHODS

The study conducted a cross-sectional survey (N = 320) of recovering adults attending 31 RCCs across New England, assessing demographic, treatment, and recovery-relevant factors, as well attitudes (positive vs. negative) toward the use of agonist and antagonist MOUD. The study used frequencies and confidence intervals to obtain prevalence estimates for positive and negative attitudes toward agonist and antagonist MOUD, and to examine differences between them. Spearman correlations identified correlates of MOUD attitudes (at p < 0.10), and significant correlates were assessed for unique contributions via multivariable logistic regression.

RESULTS

Positive attitudes were common and more prevalent than negative attitudes for both agonist (positive: 71.4 [66.1, 76.3]%; negative: 28.6 [23.7, 33.9]%) and antagonist (positive: 76.5 [71.4, 81.1]%; negative: 23.5 [18.9, 28.6]%) MOUD, which did not differ. The study identified several correlates of MOUD attitudes at the p < 0.10 level, but only four variables emerged as unique predictors controlling for other correlates. Lifetime history of agonist MOUD treatment was uniquely associated with positive agonist attitudes (p = 0.008), whereas greater social support for recovery was associated with positive antagonist attitudes (p = 0.007). Lower educational attainment was uniquely associated with negative antagonist attitudes (p = 0.005), and a greater degree of spirituality was related to negative attitudes toward both agonists (p = 0.005) and antagonists (p = 0.01).

CONCLUSIONS

Findings reveal very high rates of positive MOUD attitudes among RCC participants, highlighting the potential for this growing tier of recovery support to foster acceptance and peer support for medication-facilitated recovery pathways. Correlates of attitudes further reveal opportunities for facilitating MOUD acceptance within and beyond the RCC network.

Health professionals' attitudes toward medications for opioid use disorder

BACKGROUND

Research has shown that medications, especially opioid agonist treatments, are an effective way to treat opioid use disorder (OUD); however, negative attitudes held by health professionals contribute to their underutilization. Methods: A 23-year review of studies that examined health professionals' attitudes toward medications for OUD (MOUD) was conducted to describe the current state of knowledge and to inform future research and interventions. Results: Studies examined attitudes toward the use of methadone, buprenorphine, and naltrexone among various types of health professionals: prescribers, non-prescribing clinicians, pharmacists, and administrators. The characteristics and findings of the included studies were reviewed and synthesized. Findings indicate that attitudes toward MOUD affect access and utilization by influencing prescribing practices, referrals, and adoption within programs. Exposure, knowledge, and treatment orientation were found to be important factors related to attitudes toward MOUD across multiple studies of various types of health professionals. Conclusions: To increase access and utilization, continued efforts are needed to increase positive attitudes toward MOUD among various types of health professionals. Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers.

Organizational Facilitators and Barriers to Medication for Opioid Use Disorder Capacity Expansion and Use

Medication for opioid use disorder (MOUD) is a key strategy for addressing the opioid use disorder crisis, yet gaps in MOUD provision impede this strategy's benefits. The research reported here sought to understand what distinguishes low- and high-performing organizations in building and using capacity to provide MOUD. As part of a mixed methods MOUD implementation trial, semi-structured telephone interviews were conducted with personnel from low- and high-performing MOUD-providing organizations. Seventeen individuals from 17 organizations were interviewed. Findings demonstrate the importance of individual, organization, and community-level factors in supporting the building and use of MOUD capacity. Low- and high-performing organizations showed different patterns of facilitators and barriers during the implementation process. The key difference between low- and high-performing organizations was the level of organizational functioning. A better understanding of an organization's assets and deficits at the individual, organizational, and community levels would allow decision-makers to tailor their approaches to MOUD implementation.

Attitudes about medications for alcohol use disorder among individuals with serious mental illness: A health belief model analysis

BACKGROUND

Medications for alcohol use disorder (MAUD) are underutilized in mental health settings. Increasing use of MAUD requires increasing both the availability of these medications and the demand by individuals who could benefit. Few studies have explored the views of individuals with severe mental illness and alcohol use disorder about MAUD. We sought to examine, among individuals treated in publicly funded community mental health clinics, perceived need for and attitudes toward MAUD.

METHODS

We conducted 8 focus groups with 87 participants treated in public mental health clinics in Los Angeles County. We aimed to include individuals with a current or past AUD diagnosis and individuals helping others (e.g., a family member) who drink. We examined responses using domains associated with the Health Belief Model to identify factors that shape acceptance of MAUD.

RESULTS

Participants were 53% female; most were minorities. Average age was 47 years (SD = 11). Twenty-four reported never drinking, 13 of whom had a current or past diagnosis of AUD. Twenty-two reported drinking 4 or more times per week. Three-quarters had not heard of naltrexone. Participants understood that alcohol use has severe adverse consequences and perceived themselves to be highly susceptible to these consequences. Regarding attitudes toward MAUD, participants described an internal locus of control (e.g., their own desires, actions, and effort) as central to addressing problem drinking; this shaped their views that MAUD would have only modest benefits and potentially high burden. Those individuals who had tried MAUD expressed the most optimism about its effectiveness.

CONCLUSIONS

Participants worried MAUD would impede the development of self-control over drinking by fostering dependence on medication and undermining self-discipline. Client education and counseling that emphasizes MAUD as a tool to build clients' self-control may increase demand for these medications in mental health settings.

Intent to Refer: Exploring Bias Toward Specific Medication-Assisted Treatments by Community Corrections Employees

BACKGROUND

As opioid use increases in the United States, especially in the correctional population, the most effective treatment approaches need to be utilized. Research has shown that medication-assisted treatment (MAT) provides better outcomes than traditional treatment approaches alone, but is underutilized among correctional-supervised populations.

OBJECTIVE

This article looks at how previously identified barriers to implementing MAT can create potential biases regarding the intent to refer individuals to either buprenorphine or methadone among treatment and correctional staff within community corrections. The varying advantages of each medication are discussed to highlight the importance of individualized treatment planning.

METHODS

Data were collected from 959 treatment specialists and community-corrections officers between 2010 and 2013. The participants were employed by one of 20 community corrections agencies that were selected and randomized within a cluster design. The data were part of a larger study that tested how the experimental condition of organizational linkages impacted the use of MAT in the criminal justice system. In order to analyze the data, multinomial logistic regression was used.

RESULTS

Results showed that some community corrections employees were likely to refer clients to use methadone, but not buprenorphine (or vice versa) which was influenced by work setting, level of education, training, and negative perceptions of MAT as a substitute addiction. However, these biases could be minimized by proper training.

CONCLUSION

These findings suggest that proper training should be mandatory for these employees and include information about various MATs while also addressing the negative perception that MAT is a substitute addiction.

Assessment of barrier severity and willingness to enter opioid agonist treatment among people who inject drugs in Ukraine

BACKGROUND

Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers.

METHODS

A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT.

RESULTS

The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT.

CONCLUSIONS

Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine.

A qualitative assessment of attitudes about and preferences for extended-release naltrexone, a new pharmacotherapy to treat opioid use disorders in Ukraine

Numerous individual barriers, including negative attitudes toward opioid agonist therapies (OAT), have undermined HIV prevention efforts in Ukraine where the epidemic is concentrated in people who inject drugs (PWID). The recent availability of extended-release naltrexone (XR-NTX), an opioid antagonist, provides new opportunities for treatment and prevention, but little is known about patient preferences. We conducted qualitative analysis using focus groups (FG) of PWID recruited based on OAT experience: currently, previously, and never on OAT in five Ukrainian cities. FG included 199 PWID in 25 focus groups. Focus group transcripts were coded and analyzed using a modified grounded theory approach to identify common themes and domains related to attitudes about and preferences for XR-NTX, relative to other treatments. Interest in XR-NTX was supported if supervised opioid withdrawal and psychological support were assured. Other factors supporting XR-NTX included a focus on younger PWID early in their injection career and motivated for recovery. Perceptions of recovery included not receiving psychoactive medications like methadone or buprenorphine. With more information, XR-NTX could be a viable option for PWID in Ukraine, especially if concerns regarding withdrawal and psychological support are adequately addressed.

Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine

BACKGROUND

Opioid agonist therapies (OAT) like methadone and buprenorphine maintenance treatment remain markedly under-scaled in Ukraine despite adequate funding. Clinicians and administrators were assembled as part of an implementation science strategy to scale-up OAT using the Network for Improvement of Addiction Treatment (NIATx) approach.

METHODS

Nominal Group Technique (NGT), a key ingredient of the NIATx toolkit, was directed by three trained coaches within a learning collaborative of 18 OAT clinicians and administrators to identify barriers to increase OAT capacity at the regional "oblast" level, develop solutions, and prioritize local change projects. NGT findings were supplemented from detailed notes collected during the NGT discussion.

RESULTS

The top three identified barriers included: (1) Strict regulations and inflexible policies dictating distribution and dispensing of OAT; (2) No systematic approach to assessing OAT needs on regional or local level; and (3) Limited funding and financing mechanisms combined with a lack of local/regional control over funding for OAT treatment services.

CONCLUSIONS

NGT provides a rapid strategy for individuals at multiple levels to work collaboratively to identify and address structural barriers to OAT scale-up. This technique creates a transparent process to address and prioritize complex issues. Targeting these priorities allowed leaders at the regional and national level to advocate collectively for approaches to minimize obstacles and create policies to improve OAT services.

Overcoming Barriers to Initiating Medication-assisted Treatment for Heroin Use Disorder in a General Medical Hospital: A Case Report and Narrative Literature Review

Deaths due to heroin overdoses are increasing and are the leading cause of death among intravenous heroin users. Although medication-assisted treatment (MAT) improves morbidity and mortality in patients with opioid use disorders, it is underutilized. Most efforts to expand access to MAT have focused on outpatient settings. Although the inpatient medical setting presents a critical opportunity to initiate treatment, general hospitals are often unfamiliar with MAT, creating a number of barriers to its use. In this report, we describe the case of a woman with heroin use disorder who was initiated on buprenorphine maintenance treatment while hospitalized for cardiac disease related to her intravenous heroin use. Barriers to initiating buprenorphine in this case included patient, practitioner, and organizational factors, and, ultimately, shared misperceptions about the feasibility of administering buprenorphine in a general medical hospital. These barriers were addressed, buprenorphine was initiated, and the patient demonstrated reduced craving, improved postoperative pain control, improved overall well-being, increased engagement in discharge planning, and acceptance of referral for addiction specialty aftercare. Our experience with this patient suggests that it is feasible to initiate buprenorphine in acute medical settings and that such treatment can improve patient outcomes. Our review of the literature reveals emerging evidence supporting the value of this practice.

Extended-Release Naltrexone: A Qualitative Analysis of Barriers to Routine Use

The Medication Research Partnership (a national health plan and nine addiction treatment centers contracted with the health plan) sought to facilitate the adoption of pharmacotherapy for alcohol and opioid use disorders. Qualitative analysis of interviews with treatment center change leaders, individuals working for the manufacturer and its technical assistance contractor, and health plan managers extracted details on the processes used to order, store, bill for, and administer extended-release naltrexone. Qualitative themes were categorized using domains from the Consolidated Framework for Implementation Research (intervention characteristics, outer setting, inner setting, and provider characteristics). Characteristics of XR-NTX that inhibited use included the complexity of ordering and using the medication; cost was also a barrier. Outer setting barriers reflected patient needs and external health plan policies on formulary coverage, benefit management, and reimbursement. Program structures, the lack of physician linkages, a culture resistant to the use of medication, and unease with change were inner setting elements that limited use of XR-NTX. Patient stereotypes and a lack of knowledge about XR-NTX affected practitioner willingness to treat patients and prescribe XR-NTX. The Consolidated Framework for Implementation Research provided a useful lens to understand and interpret the processes affecting access to XR-NTX.

Counselor Attitudes Toward Contingency Management for Substance Use Disorder: Effectiveness, Acceptability, and Endorsement of Incentives for Treatment Attendance and Abstinence

Despite research demonstrating its effectiveness, use of contingency management (CM) in substance use disorder treatment has been limited. Given the vital role that counselors play as arbiters in the use of therapies, examination of their attitudes can provide insight into how further use of CM might be effectively promoted. In this paper, we examine 731 counselors' attitudes toward the effectiveness and acceptability of CM in treatment, as well as their specific attitudes toward both unspecified and tangible incentives for treatment attendance and abstinence. Compared to cognitive behavioral therapy, motivational interviewing, and community reinforcement approach, counselors rated CM as the least effective and least acceptable psychosocial intervention. Exposure through the use of CM in a counselor's employing organization was positively associated with perceptions of acceptability, agreement that incentives have a positive effect on the client-counselor relationship, and endorsement of tangible incentives for abstinence. Endorsement of tangible incentives for treatment attendance was significantly greater among counselors with more years in the treatment field, and counselors who held at least a master's degree. Counselors' adaptability or openness to innovations was also positively associated with attitudes toward CM. Further, female counselors and counselors with a greater 12-step philosophy were less likely to endorse the use of incentives. A highlight of our study is that it offers the first specific assessment of the impact of "Promoting Awareness of Motivational Incentives" (PAMI), a Web-based tool based on findings of CM protocols tested within the Clinical Trials Network (CTN), on counselors employed outside the CTN. We found that 10% of counselors had accessed PAMI, and those who had accessed PAMI were more likely to report a higher degree of perceived effectiveness of CM than those who had not. This study lays the groundwork for vital research on the impact of multiple Web-based educational strategies. Given the barriers to CM adoption, identifying predictors of positive attitudes among counselors can help diffuse CM into routine clinical practice.

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.

Effect of an organizational linkage intervention on staff perceptions of medication-assisted treatment and referral intentions in community corrections

INTRODUCTION

Medication-assisted treatment (MAT) is effective for alcohol and opioid use disorders but it is stigmatized and underutilized in criminal justice settings.

METHODS

This study cluster-randomized 20 community corrections sites to determine whether an experimental implementation strategy of training and an organizational linkage intervention improved staff perceptions of MAT and referral intentions more than training alone. The 3-hour training was designed to address deficits in knowledge, perceptions and referral information, and the organizational linkage intervention brought together community corrections and addiction treatment agencies in an interagency strategic planning and implementation process over 12 months.

RESULTS

Although training alone was associated with increases in familiarity with pharmacotherapy and knowledge of where to refer clients, the experimental intervention produced significantly greater improvements in functional attitudes (e.g. that MAT is helpful to clients) and referral intentions. Corrections staff demonstrated greater improvements in functional perceptions and intent to refer opioid dependent clients for MAT than did treatment staff.

CONCLUSION

Knowledge, perceptions and information training plus interorganizational strategic planning intervention is an effective means to change attitudes and intent to refer clients for medication assisted treatment in community corrections settings, especially among corrections staff.

'Miracle cure' or 'liquid handcuffs': reporting on naltrexone and methadone in the Australian print media

INTRODUCTION AND AIMS

The news media is an important source of information regarding new developments in medicine and public health interventions. Previous research has indicated that in many cases, reporting on new treatments can be inaccurate or sensationalist. This paper presents analysis of Australian print media reporting on two treatment options for heroin dependence (naltrexone and methadone). The aim of this study was to quantitatively compare the volume and content of Australian print media reporting on these two treatments, one of which had a long history of use in Australia, and the other which was comparatively newer.

DESIGN AND METHODS

The study constituted a quantitative content analysis of a sample of 859 Australian newspaper articles, published over a 10-year period (1997-2007). Each article paragraph was coded for positive outcomes/benefits of treatment, as well as negative outcomes associated with treatment.

RESULTS

The analysis revealed that during this period, the Australian print media was significantly more likely to report the potential positive outcomes of naltrexone treatment, compared with the negative outcomes. In contrast, reporting on methadone focused more on the negative outcomes and side effects.

DISCUSSION AND CONCLUSIONS

The relative frequency by which the benefits of naltrexone were mentioned in this sample of news content is somewhat at odds with the extant efficacy and effectiveness research evidence. The findings suggest that reporting on these treatments in the Australian print media has not been balanced. This type of reporting has potential implications for public attitudes, as well as policy decisions.

A cluster randomized trial of an organizational linkage intervention for offenders with substance use disorders: study protocol

BACKGROUND

Substance use disorders are highly prevalent in community correctional populations, yet these settings frequently are ill-equipped to identify and refer offenders to community-based treatment services. In particular, community corrections staff are often opposed to the use of medication in addiction treatment because of inadequate knowledge, resources, and organizational structures to facilitate client linkages to evidence-based services.

METHODS/DESIGN

Each of the NIDA-funded Research Centers recruited 2 criminal justice agencies to participate in the study. Eligibility rules required study sites that were focused on community corrections (i.e., probation or parole), had few or no formal relationships with treatment providers for referring clients to medication-assisted treatment, and had no state or local policies prohibiting such relationships. Sites under the oversight of the same parent agency were eligible only if they were in geographically distinct catchment areas, and could be assigned to different study arms without cross-contamination at any level. The 18 clusters consisted of community corrections officers and their offender caseloads nested within agencies, each of which was partnered with at least one community-based substance abuse treatment program. Randomization was blocked by Research Center, within which one cluster was randomly assigned to a training-only condition (comparison) and the other to training followed by a strategic organizational linkage process (intervention). Line staff received a scientifically-grounded, systematically-delivered training session that addresses gaps in existing knowledge, perceptions, and information about medication-assisted treatment (MAT) and local availability of MAT services. Key decision-makers subsequently were asked to collaborate in a strategic planning process to enhance formal and informal linkages between criminal justice agencies and local MAT providers. It was hypothesized that the two implementation intervention components together would be more likely than staff training alone to improve the process of referring opioid- and alcohol-dependent adults under community supervision to appropriate addiction pharmacotherapy. Outcomes were measured at the client (referrals), line staff (attitudes), and organizational (linkage) levels.

DISCUSSION

Through closer collaboration among criminal justice agencies and treatment providers, improved linkages to effective substance abuse treatment should yield significant clinical, public health and public safety benefits.

Comparison of buprenorphine treatment for opioid dependence in 3 settings

Although use of buprenorphine in the treatment of opioid dependence is expected to continue to increase, little is known about the optimal setting for providing the medical and psychosocial care required with buprenorphine pharmacotherapy.

OBJECTIVE

This study compared buprenorphine therapy delivered in 3 distinct treatment settings: an opioid treatment program (OTP) offering individual counseling, a group counseling program utilizing the manualized Matrix Model (MMM) of cognitive-behavioral treatment, and a private clinic setting mirroring standard medical management for buprenorphine treatment provided specifically at a psychiatrist's private practice (primary care setting).

METHOD

Participants were inducted on buprenorphine and provided with treatment over a 52-week study duration. All participants were scheduled for weekly treatment visits for the first 6 study weeks and 2 sites reduced treatment to monthly visits for dispensing of medication and psychosocial counseling. Outcomes include opioid use, participant retention in treatment, and treatment participation.

RESULTS

Participants presenting for treatment at the sites differed only by race/ethnicity and opioid use did not differ by site. Retention differed by treatment site, with the number of participants who stayed in the study until the end of 20 weeks significantly associated with treatment site. The mean number of minutes spent in each individual counseling session also differed by site. Although no difference in opioid use by treatment site was found, results document a significant association between opioid use and buprenorphine dose.

DISCUSSION

These results show some differences by treatment site, although the similarity and relative ease in which the sites were able to recruit participants for treatment with buprenorphine, and minor implementation problems reported suggests the feasibility of treatment with buprenorphine across various treatment settings.

CONCLUSION

Similar rates of continued opioid use across study sites and few qualitative reports of problems indicates that treatment with buprenorphine and associated psychosocial counseling are safe and relatively easy to implement in a variety of treatment settings.

A multilevel approach to predicting community addiction treatment attitudes about contingency management

Adoption of contingency management (CM) by the addiction treatment community is limited to date despite much evidence for its efficacy. This study examined systemic and idiographic staff predictors of CM adoption attitudes via archival data collected from treatment organizations affiliated with the National Drug Abuse Treatment Clinical Trials Network. Multilevel modeling analyses evaluated potential predictors from organizational, treatment unit, and workforce surveys. Among these were individual and shared perceptions of staff concerning aspects of their clinic culture and climate. Modeling analyses identified three systemic predictors (clinic provision of opiate agonist services, national accreditation, and lesser shared perception of workplace stress) and five idiographic predictors (staff with a graduate degree, longer service tenure, managerial position, e-communication facility, and openness to change in clinical procedures). Findings are discussed as they relate to extant literature on CM attitudes and established implementation science constructs, and their practical implications are discussed.

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.

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.

Addicted to discovery: Does the quest for new knowledge hinder practice improvement?

Despite the billions of dollars spent on health-focused research and the hundreds of billions spent on delivering health services each year, relatively little money and effort are directed toward investigating how best to connect the two. This results in missed opportunities to assure that research findings inform and improve quality across healthcare in general and for addiction prevention and treatment in particular. There is an asymmetrical focus that favors the identification of new interventions and neglects the implementation of science-based knowledge in actual practice. The consequences of that neglect are severe: significantly diminished progress in research on how to implement treatments that could improve the lives of persons with addiction problems, their families, and the rest of society. While the advancement of knowledge regarding effective implementation is lagging, it is clear that existing systemic incentives in the conduct of science inhibit rather than facilitate widespread adoption of evidence-based practices. This commentary proposes three interrelated strategies for improving the implementation process. First, develop scientific tools to understand implementation better, by expanding investigations on the science of implementation and broadening approaches to the design and execution of research. Second, nurture and support a collaborative implementation workforce comprised of scientists and on-the-ground practitioners, with an explicit focus on enhancing appropriate incentives for both. Third, pay closer attention to crafting research that seeks answers that are most relevant to clinicians' actual needs, primarily by ensuring that the anticipated users of the evidence-based practice are full partners in developing the questions right from the start.

From research to the real world: buprenorphine in the decade of the Clinical Trials Network

The National Institute on Drug Abuse (NIDA) established the National Drug Abuse Treatment Clinical Trials Network (CTN) in 1999 to bring researchers and treatment providers together to develop a clinically relevant research agenda. Initial CTN efforts addressed the use of buprenorphine, a mu-opioid partial agonist, as treatment for opioid dependence. Strong evidence of buprenorphine's therapeutic efficacy was demonstrated in clinical trials involving several thousand opioid-dependent participants, and in 2002, the Food and Drug Administration approved buprenorphine for the treatment of opioid dependence. With the advent of a sublingual tablet containing both buprenorphine and naloxone to mitigate abuse and diversion (Suboxone), buprenorphine appeared poised to be the first-line treatment for opioid addiction. Notwithstanding its many attributes, certain implementation barriers remained to be addressed in CTN studies, and these efforts have brought a body of knowledge on buprenorphine to frontline clinicians. The purpose of this article is to review CTN-based buprenorphine research and related efforts to overcome challenges to the implementation of buprenorphine therapy in mainstream practice. Furthermore, this article explores current issues and future challenges that may require additional CTN efforts.