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

A qualitative analysis of barriers to opioid agonist treatment for racial/ethnic minoritized populations

INTRODUCTION

Clinical guidelines strongly recommend opioid agonist treatment (OAT) as first-line treatment for opioid use disorder (OUD). However, racial/ethnic minoritized patients are less likely to receive OAT compared to non-Hispanic White patients. Reasons for this treatment gap must be elucidated to address racial/ethnic disparities in OAT. Our objective is to evaluate perceptions of and barriers to OAT across racial/ethnic groups in individuals with OUD (not on OAT).

METHODS

This qualitative study used semi-structured telephone interviews of adult patients (n = 41) with OUD (not currently being treated with OAT) from the Boston area from September 2020 through February 2021. We developed a codebook through author consensus based on review of themes in initial transcripts. We performed qualitative thematic analysis of the transcripts. We evaluated patients' perceptions of treatment for OUD across the study population and analyzed differences and similarities in perceptions between racial and ethnic groups.

RESULTS

Across all racial/ethnic categories in our sample, anticipated stigma was the most frequently reported barrier to OAT and most patients preferred non-OAT methods for treatment. Non-Hispanic White participants had more favorable opinions of OAT compared to racial/ethnic minoritized participants. Racial/ethnic minoritized participants reported social support as the main facilitator to addiction treatment, while non-Hispanic White participants reported self-motivation as the most important factor. Racial/ethnic minoritized participants preferred treatment for OUD via non-OAT treatments and their second most preferred option was residential treatment. Non-Hispanic White participants preferred naltrexone and their second most preferred option was non-OAT treatments.

CONCLUSIONS

Racial/ethnic minoritized patients' preference for residential treatment and social support, along with their distrust of OAT, illustrates a desire for psychosocial and peer recovery-based care that addresses social determinants of health. Addiction specialists may improve engagement with and treatment of racial/ethnic minoritized groups with culturally tailored interventions for OUD that offer psychosocial treatment in combination with OAT, and by partnering with organizations with strong ties to racial/ethnic minoritized communities. This kind of response would reflect the structural and cultural humility that is needed to adequately address the OUD needs of these underserved populations.

Stepped implementation-to-target: a study protocol of an adaptive trial to expand access to addiction medications

BACKGROUND

In response to the US opioid epidemic, significant national campaigns have been launched to expand access to `opioid use disorder (MOUD). While adoption has increased in general medical care settings, specialty addiction programs have lagged in both reach and adoption. Elevating the quality of implementation strategy, research requires more precise methods in tailoring strategies rather than a one-size-fits-all-approach, documenting participant engagement and fidelity to the delivery of the strategy, and conducting an economic analysis to inform decision making and policy. Research has yet to incorporate all three of these recommendations to address the challenges of implementing and sustaining MOUD in specialty addiction programs.

METHODS

This project seeks to recruit 72 specialty addiction programs in partnership with the Washington State Health Care Authority and employs a measurement-based stepped implementation-to-target approach within an adaptive trial design. Programs will be exposed to a sequence of implementation strategies of increasing intensity and cost: (1) enhanced monitoring and feedback (EMF), (2) 2-day workshop, and then, if outcome targets are not achieved, randomization to either internal facilitation or external facilitation. The study has three aims: (1) evaluate the sequential impact of implementation strategies on target outcomes, (2) examine contextual moderators and mediators of outcomes in response to the strategies, and (3) document and model costs per implementation strategy. Target outcomes are organized by the RE-AIM framework and the Addiction Care Cascade.

DISCUSSION

This implementation project includes elements of a sequential multiple assignment randomized trial (SMART) design and a criterion-based design. An innovative and efficient approach, participating programs only receive the implementation strategies they need to achieve target outcomes. Findings have the potential to inform implementation research and provide key decision-makers with evidence on how to address the opioid epidemic at a systems level.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT05343793) on April 25, 2022.

Comparing Perceptions of Addiction Treatment between Professionals and Individuals in Recovery

Background: The purpose of this qualitative study was to compare and contrast the differing perspectives of service users and professionals regarding the current substance use disorders (SUD) services provided in Summit County, Ohio. Seven focus groups were conducted with 44 participants (52.3% male, mean age 46 years), including 15 individuals in recovery, 16 direct service providers, and 13 executive directors. The participants were asked about three areas: (1) effective treatment for SUD, (2) challenges for persons with SUD, and (3) suggestions for improving SUD treatment outcomes. The data were analyzed and coded according to major themes. Results: While there were numerous emergent themes that were concordant between service use and professionals, several differing themes between the groups were also identified. First, participants disagreed on the effectiveness of medication-assisted treatment/Medications for Opioid Use Disorder. Second, professionals identified trauma, stigma, "one-size-fits-all" approach to treatment, and limitations set by managed care act as barriers to treatment, whereas individuals in recovery reported difficulty dealing with feelings, feeling of being rushed into recovery, and the lack of long-term recovery plans as the most significant barriers. Lastly, in order to improve treatment outcomes, professionals emphasized the importance of education unlike individuals in recovery who identified sober supports as the most important factor. Conclusion: This study identified challenges in SUD recovery and highlights essential areas for consideration when developing and implementing SUD treatment. The findings can be used as guidelines to provide better services to individuals with SUDs.Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2022.2058706 .

Characteristics of adults reporting illicitly manufactured fentanyl or heroin use or prescription opioid misuse in the United States, 2019

BACKGROUND

Deaths involving illicitly manufactured fentanyl (IMF) have increased since 2013 in the United States. Little research has examined individuals using IMF. This study aims to explore the characteristics of US adults who used IMF, heroin, or misused prescription opioids and examine the associations between demographic, clinical, psychosocial characteristics and IMF use.

METHODS

A convenience sample of adults aged ≥ 18 years being assessed for substance use disorder (SUD) treatment was collected between January-December 2019 using the Addiction Severity Index-Multimedia Version instrument. We used a multivariable logistic regression model to examine the associations between demographic, clinical, psychosocial characteristics and IMF use.

RESULTS

Adults reporting IMF as their primary lifetime substance use problem also reported using other substances-most often alcohol or heroin-both in the past 30 days and during their lifetime. Characteristics associated with increased odds of reporting IMF as the primary lifetime substance use problem included age 18-24 years (adjusted odds ratio (aOR) = 1.68; 95% confidence interval (CI) = 1.18-2.38) versus 45-54 years, non-Hispanic Black persons (aOR = 1.44; 95% CI = 1.11-1.85) versus non-Hispanic White persons, being assessed in Northeast (aOR = 15.46; 95% CI = 8.67-27.56) versus West, and having a history of at least one lifetime overdose (1 overdose (aOR = 1.91; 95% CI = 1.49-2.44); 2 overdoses (aOR = 1.95; 95% CI = 1.48-2.58); 3 or more overdoses (aOR = 2.27; 95% CI = 1.82-2.82)).

CONCLUSIONS

These findings provide new insights into this high-risk population and help identify strategies to address increasing overdose death rates involving IMF. Opportunities for intervention include expanding naloxone distribution and harm reduction programs and connecting individuals with nonfatal overdoses to SUD treatment.

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.

The opioid crisis: a contextual, social-ecological framework

The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

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.

Patient decision aid for medication treatment for opioid use disorder (PtDA-MOUD): Rationale, methodology, and preliminary results

BACKGROUND AND AIMS

As treatment for opioid use disorder (OUD) expands within general healthcare settings such as primary care, mechanisms to facilitate decision-making processes are increasingly necessary. Decision aids have the capacity to bolster existing resources in diverse treatment settings by increasing knowledge of treatment options and facilitating shared decision making. The aim of this study is to develop and test a patient decision aid for medication treatment for opioid use disorder (PtDA-MOUD) that assists individuals with OUD in making informed decisions about treatment at the time of initial clinical visit. Use of the PtDA-MOUD will be further tested in diverse treatment settings within the California Hub and Spoke System developed under the SAMHSA State Targeted Response to the Opioid Crisis grants.

METHODS

The PtDA-MOUD was iteratively developed with input from a scientific expert panel and both patient and provider focus groups, incorporating International Patient Decision Aid Standards. Thirty-six patients with OUD entering treatment pilot tested the PtDA and completed assessments, and results from clinical records were compared with matched controls who did not receive the PtDA. A clinical profile based on assessment data was created for use within the clinical visit.

RESULTS

The developed decision aid provides information on MOUD and captures patient characteristics relevant to medication treatment decisions. Feedback indicated that the PtDA-MOUD was feasible to implement and useful. Though the small sample size limited the ability to detect significant differences (p > .05), a greater number of individuals who reviewed the PtDA (37%) were inducted on MOUD than controls (11%) and received MOUD for more days (M = 14.0, SD = 24.7) than controls (M = 8.4; SD = 22.5). Moreover, the difference in means for days receiving MOUD had an approximately medium effect size (r = 0.25).

CONCLUSIONS

Patient perceptions of the decision aid were favorable and it showed promise as a tool in the OUD treatment process. Pilot testing results suggested preliminary positive effects on MOUD initiation. Future phases of this study will further investigate the usefulness of this tool. ClinicalTrials.govIdentifier:NCT03394261.

State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder

OBJECTIVE

As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.

METHODS

This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs.

RESULTS

State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049).

CONCLUSIONS

State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario

OBJECTIVE

To examine use of first-line alcohol use disorder (AUD) medications (naltrexone and acamprosate) among public drug plan beneficiaries in the year following an AUD diagnosis.

DESIGN

Retrospective population-based cohort study.

SETTING

Ontario.

PARTICIPANTS

Individuals eligible for public drug plan benefits who had an AUD diagnosis at a hospital visit between April 1, 2011, and March 31, 2012.

MAIN OUTCOME MEASURES

Number of AUD medications dispensed to public drug plan beneficiaries who had a recent hospital visit with an AUD diagnosis, and number of prescriptions dispensed per person.

RESULTS

A total of 10 394 Ontarians between 18 and 65 years of age were identified who had a hospital visit with an AUD diagnosis and were eligible for public drug plan benefits. The rate of AUD medications dispensed in the subsequent year was 3.56 per 1000 population (95% CI 2.51 to 4.91; n = 37). This rate did not differ significantly by sex (P = .83).

CONCLUSION

Very few public drug plan beneficiaries are dispensed first-line AUD medications in the year following an AUD diagnosis.

Access to Addiction Pharmacotherapy in Private Health Plans

BACKGROUND

An increasing number of medications are available to treat addictions. To understand access to addiction medications, it is essential to consider the role of private health plans. To contain medication expenditures, most U.S. health plans use cost-sharing and administrative controls, which may impact physicians' prescribing and patients' use of addiction medications. This study identified health plan approaches to manage access to and utilization of addiction medications (oral and injectable naltrexone, acamprosate, and buprenorphine).

METHODS

Data are from a nationally representative survey of private health plans in 2010 (n=385 plans, 935 products; response rate 89%), compared to the same survey in 2003. The study assessed formulary inclusion, prior authorization, step therapy, overall restrictiveness, and if and how health plans encourage pharmacotherapy.

RESULTS

Formulary exclusions were rare in 2010, with acamprosate excluded most often, by only 9% of products. Injectable naltrexone was covered by 96% of products. Prior authorization was common for injectable naltrexone (85%) and rare for acamprosate (3%). Step therapy policies were used only for injectable naltrexone (41%) and acamprosate (20%). Several medications were often on the most expensive tier. Changes since 2003 include fewer exclusions, yet increased use of other management approaches. Most health plans encourage use of addiction pharmacotherapy, and use a variety of methods to do so.

CONCLUSIONS

Management of addiction medications has increased over time but it is not ubiquitous. However, health plans now also include all medications on formularies and encourage providers to use them, indicating that they value addiction pharmacotherapy as an evidence-based practice.

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.

The Diffusion of Acamprosate for the Treatment of Alcohol Use Disorder: Results From a National Longitudinal Study

To consider how the Affordable Care Act may impact the diffusion of acamprosate, an evidence-based treatment for alcohol use disorder (AUD), the present study estimated the associations between acamprosate availability, Medicaid revenues, and private insurance revenues. Data were collected from organizational leaders of national samples of 307 specialty treatment centers in 2009-2012 and 372 treatment centers in 2011-2013. Notably, there was not a significant change in the percentage of organizations offering acamprosate over the study period. However, greater reliance on Medicaid and private insurance as sources of revenue was positively associated with the availability of acamprosate. In addition, acamprosate availability was positively associated with access to physicians and the presence of on-site primary medical care, while centers that placed greater emphasis on confrontational group therapy were significantly less likely to offer acamprosate for AUD treatment. To the extent that the ACA is expanding the number of insured individuals enrolled in Medicaid and commercial insurance sold through health insurance exchanges, this study suggests that the ACA may hold promise for expanding the availability of this EBP for AUD treatment. Future research is needed to measure whether this potential impact actually occurs within the specialty treatment system over time.

Comparative utilization of pharmacotherapy for alcohol use disorder and other psychiatric disorders among U.S. Veterans Health Administration patients with dual diagnoses

Patients with alcohol use disorder (AUD) and another co-occurring psychiatric disorder are a vulnerable population with high symptom severity. Such patients may benefit from a full arsenal of treatment options including pharmacotherapy. Receipt of AUD pharmacotherapy is generally very low despite recommendations that it be made available to every patient with AUD, including those with co-occurring disorders. Little is known about pharmacotherapy rates for AUD compared to other psychiatric disorders among patients with dual diagnoses. This study compared rates of pharmacotherapy for AUD to those for non-substance use psychiatric disorders and tobacco use disorder among patients with dual diagnoses in the U.S. Veterans Affairs (VA) healthcare system. VA data were used to identify patients with AUD and another psychiatric disorder in fiscal year 2012, and to estimate the proportion receiving pharmacotherapy for AUD and for each comorbid condition. Among subsets of patients with AUD and co-occurring schizophrenic, bipolar, posttraumatic stress or major depressive disorder, receipt of medications for AUD ranged from 7% to 11%, whereas receipt of medications for the comorbid disorder ranged from 69% to 82%. Among patients with AUD and co-occurring tobacco use disorder, 6% received medication for their AUD and 34% for their tobacco use disorder. Among patients with dual diagnoses, rates of pharmacotherapy for AUD were far lower than those for the comorbid disorders and contrary to evidence that medications for AUD are effective. Additional system-wide implementation efforts to identify and address patient- and provider-level barriers are needed to increase AUD pharmacotherapy in this high-need population.

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.

Innovation attributes and adoption decisions: perspectives from leaders of a national sample of addiction treatment organizations

Drawing on diffusion theory to further knowledge about evidence-based practices (EBPs) in the treatment of substance use disorders (SUDs), this study describes the perceived importance of innovation attributes in adoption decisions within a national sample of SUD treatment organizations. Face-to-face interviews were conducted with leaders of 307 organizations. A typology differentiated organizations reporting: (1) adoption of a treatment innovation in the past year ("recent adoption"), (2) plans to adopt an innovation in the upcoming year ("planned adoption"), or (3) no actual or planned adoption ("non-adoption"). About 30.7% of organizations reported recent adoption, 20.5% indicated planned adoption, and 48.8% were non-adopters. Leaders of organizations reporting recent adoption (n=93) or planned adoption (n=62) rated the importance of innovation attributes, including relative advantage, compatibility, complexity, and observability, on these adoption decisions using a Likert scale that ranged from 0 to 5. Innovation attributes most strongly endorsed were consistency with the program's treatment philosophy (mean=4.47, SD=1.03), improvement in the program's reputation with referral sources (mean=4.00, SD=1.33), reputational improvement with clients and their families (mean=3.98, SD=1.31), and reductions in treatment dropout (mean=3.75, SD=1.54). Innovation characteristics reflecting organizational growth and implementation costs were less strongly endorsed. Adopters and planners were generally similar in their importance ratings. There were modest differences in importance ratings when pharmacological innovations were compared to psychosocial interventions. These findings are consistent with diffusion theory and suggest that efforts to link EBPs with client satisfaction and potential reputational benefits may enhance the diffusion of EBPs. Attention to these attributes when developing and evaluating SUD treatment interventions may enhance efforts to increase subsequent adoption.

The transition to medication adoption in publicly funded substance use disorder treatment programs: organizational structure, culture, and resources

OBJECTIVE

Medications for the treatment of substance use disorders (SUDs) are not widely available in publicly funded SUD treatment programs. Few studies have drawn on longitudinal data to examine the organizational characteristics associated with programs transitioning from not delivering any pharmacotherapy to adopting at least one SUD medication.

METHOD

Using two waves of panel longitudinal data collected over a 5-year period, we measured the transition to medication adoption in a cohort of 190 publicly funded treatment organizations that offered no SUD medications at baseline. Independent variables included organizational characteristics, medical resources, funding, treatment culture, and detailing activities by pharmaceutical companies.

RESULTS

Of 190 programs not offering SUD pharmacotherapy at baseline, 22.6% transitioned to offering at least one SUD medication at follow-up approximately 5 years later. Multivariate logistic regression results indicated that the employment of at least one physician at baseline, having a greater proportion of Medicaid clients, and pharmaceutical detailing were positively associated with medication adoption.

CONCLUSIONS

Adoption of pharmacotherapy was more likely in programs that had greater medical resources, Medicaid funding, and contact with pharmaceutical companies. Given the potential expansion of Medicaid under the Affordable Care Act, patients served by publicly funded programs may gain greater access to such treatments, but research is needed to document health reform's impact on this sector of the treatment system.

Science-based and practice-based innovativeness and performance of substance abuse treatment facilities

BACKGROUND

The fields of mental health and substance abuse treatment lag significantly behind other health care organizational fields in the adoption, implementation, and dissemination of evidence-based practices. Innovative organizational practices may be science based or practice based. The implementation of innovative practices requires considerable organizational resources. Whether this organizational investment actually pays off in terms of superior performance is unclear. This issue in the context of substance abuse treatment facilities (SATFs) in the United States is examined in this study.

PURPOSE

The purpose of this study is to examine the influence of the use of innovative organizational practices, both science based (psychosocial interventions) and practice based, on the organizational performance of SATFs.

METHODOLOGY/APPROACH

The study uses cross-sectional data on 13,513 SATFs in the United States, obtained from the National Survey of Substance Abuse Treatment Services 2009 database.

FINDINGS

Multinomial logistic regression models find a positive association between the use of science-based innovations and practice-based innovations and organizational performance, that is, the provision of comprehensive (core and wraparound) services. SATFs that were located in metropolitan areas, those accredited by the Commission on Accreditation of Rehabilitation Facilities and Joint Commission, that had a mixed (Substance Abuse and Mental Health) focus or were recipients of earmark funds also had higher organizational performance.

PRACTICE IMPLICATIONS

The results signify that substance abuse facilities that are high innovators in terms of implementing science based and practice-based innovative practices have higher organizational performance. Organizations that have institutionalized these practices have invested considerable resources in innovation. The shown higher organizational performance provides justification for the organizational investment in innovation.

Examining the sustainment of the Adolescent-Community Reinforcement Approach in community addiction treatment settings: protocol for a longitudinal mixed method study

BACKGROUND

Although evidence-based treatments are considered the gold standard for clinical practice, it is widely recognized that evidence-based treatment implementation in real world practice settings has been limited. To address this gap, the federal government provided three years of funding, training and technical assistance to 84 community-based treatment programs to deliver an evidence-based treatment called the Adolescent-Community Reinforcement Approach (A-CRA). Little is known about whether such efforts lead to long-term A-CRA sustainment after the initial funding ends.

METHODS/DESIGN

We will use a longitudinal mixed method data analytic approach to characterize sustainment over time and to examine the factors associated with the extent to which A-CRA is sustained. We will use implementation data collected during the funding period (e.g., organizational functioning, staff certification rates and penetration) and supplement it with additional data collected during the proposed project period regarding implementation quality and the hypothesized predictors of sustainment (i.e., inner and outer contextual variables) collected over three waves from 2013 to 2015 representing program sustainment up to five years post-initial funding.

DISCUSSION

Gaining a better understanding of the factors that influence the evidence-based treatment sustainment may lead to more effective dissemination strategies and ultimately improve the quality of care being delivered in community-based addiction treatment settings.

Dissemination, adoption, and implementation of acamprosate for treating alcohol use disorders

OBJECTIVE

Acamprosate has been available in the United States for treating alcohol use disorders (AUDs) for nearly a decade, yet few studies have examined its use within AUD treatment organizations. In addition to describing dissemination and adoption of acamprosate, this study provides novel data regarding organizational processes that underlie its implementation within adopting programs.

METHOD

Data were drawn from interviews with leaders of a nationally representative sample of 307 organizations delivering AUD treatment. Quantitative indicators of organizational characteristics, dissemination, adoption, and implementation of acamprosate, as well as qualitative measures of implementation processes, were measured during face-to-face interviews.

RESULTS

Only 18.0% (n = 55) of sampled organizations had adopted acamprosate for treating AUDs, and adoption was positively associated with accreditation, having a physician on staff, receiving information about acamprosate via pharmaceutical representatives, and learning about this medication from other treatment providers. Within adopting programs, an average of 6.0% of AUD patients were currently receiving acamprosate. Numerous implementation challenges were identified, including appropriate patient selection, patient reluctance to be prescribed acamprosate, suboptimal adherence, its costs, and limited counselor training.

CONCLUSIONS

The limited adoption and implementation of acamprosate likely limits the potential public health impact of this adjunct to AUD treatment. Research integrating the perspectives of organizational leaders, medical professionals, and patients is needed to determine whether specific strategies can address the implementation challenges identified in the current study and increase use of acamprosate in specialty AUD treatment settings.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings

BACKGROUND

Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence.

METHODS/DESIGN

Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence.

DISCUSSION

We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices.

TRIAL REGISTRATION

NCT01615237.

Implementing drug abuse treatment services in criminal justice settings: Introduction to the CJ-DATS study protocol series

BACKGROUND

Despite a growing pipeline of effective clinical treatments, there remains a persistent research-to-practice gap in drug abuse services. Delivery of effective treatment services is especially lacking in the U.S. criminal justice system, where half of all incarcerated persons meet the need for drug abuse or dependence, yet few receive needed care. Structural, financial, philosophical and other barriers slow the pace of adoption of available evidence-based practices. These challenges led to the development of a multi-site cooperative research endeavor known as the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), funded by the National Institute on Drug Abuse (NIDA). CJ-DATS engages university-based research teams, criminal justice agencies, and community-based treatment providers in implementation research studies to test strategies for enhancing treatment service delivery to offender populations.

METHODS

This Introduction reviews the mission of NIDA, the structure and goals of the CJ-DATS cooperative, and the implementation studies being conducted by the participating organizations. The component Study Protocols in this article collection are then described.

DISCUSSION

CJ-DATS applies implementation science perspectives and methods to address a vexing problem - the need to link offender populations with effective treatment for drug abuse, HIV, and other related conditions for which they are at high risk. Applying these principles to the U.S. criminal justice system is an innovative extension of lessons that have been learned in mainstream healthcare settings. This collection is offered as both an introduction to NIDA's work in this area, as well as a window onto the challenges of conducting health services research in settings in which improving public health is not the organization's core mission.

The employment of nurses in publicly funded substance abuse treatment programs

Little is known about the organizational and environmental factors associated with the employment of nurses in substance abuse treatment programs. Using data collected from the administrators of 250 publicly funded substance abuse treatment programs, this study examined the organizational and environmental correlates of nurse employment in these settings. Negative binomial regression models indicated that the number of nurses employed by treatment programs was positively associated with government ownership, location within a healthcare setting, and the availability of detoxification services. Outpatient-only programs employed fewer nurses than programs with inpatient/residential services. Two environmental factors were associated with nurse employment. Programs that more strongly endorsed a scale of financial barriers employed significantly fewer nurses, whereas programs indicating that funding from state contracts could be used to pay for healthcare providers employed significantly more nurses. These findings suggest that organizational decisions about employing nurses may reflect both the characteristics of the program and the funding environment. Future research should continue to examine the employment of nurses in substance abuse treatment settings, particularly given the shifting environment due to the implementation of healthcare reform.

Adoption of evidence-based clinical innovations: the case of buprenorphine use by opioid treatment programs

This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.

Financial factors and the implementation of medications for treating opioid use disorders

OBJECTIVES

Despite the established effectiveness of pharmacotherapies for treating opioid use disorders, implementation of medications for addiction treatment (MAT) by specialty treatment programs is limited. This research examined relationships between organizational factors and the program-level implementation of MAT, with attention paid to specific sources of funding, organizational structure, and workforce resources.

METHODS

Face-to-face structured interviews were conducted in 2008 to 2009 with administrators of 154 community-based treatment programs affiliated with the National Institute on Drug Abuse's Clinical Trials Network; none of these programs exclusively dispensed methadone without offering other levels of care. Implementation of MAT was measured by summing the percentages of opioid patients receiving buprenorphine maintenance, methadone maintenance, and tablet naltrexone. Financial factors included the percentages of revenues received from Medicaid, private insurance, criminal justice, the Federal block grant, state government, and county government. Organizational structure and workforce characteristics were also measured.

RESULTS

Implementation of MAT for opioid use disorders was low. Greater reliance on Medicaid was positively associated with implementation after controlling for organizational structure and workforce measures, whereas the association for reliance on criminal justice revenues was negative.

CONCLUSIONS

The implementation of MAT for opioid use disorders by specialty addiction treatment programs may be facilitated by Medicaid but may be impeded by reliance on funding from the criminal justice system. These findings point to the need for additional research that considers the impact of organizational dependence on different types of funding on patterns of addiction treatment practice.

Disparities in access to physicians and medications for the treatment of substance use disorders between publicly and privately funded treatment programs in the United States

OBJECTIVE

Prior research suggests that publicly funded substance use disorder (SUD) treatment programs lag behind privately funded programs in adoption of evidence-based practices, resulting in disparities in access to high-quality SUD treatment. These disparities highlight a critical public health concern because the majority of SUD patients in the United States are treated in the publicly funded treatment sector. This study uses recent data to examine disparities in access to physicians and availability of medications for the treatment of SUDs between publicly and privately funded SUD treatment programs.

METHOD

Data were collected from 595 specialty SUD treatment programs from 2007 to 2010 via face-to-face interviews, mailed surveys, and telephone interviews with treatment program administrators.

RESULTS

Publicly funded programs were less likely than privately funded programs to have a physician on staff, even after controlling for several organizational characteristics that were associated with access to physicians. The results of negative binomial regression indicated that, even after taking into account physician access and other organizational variables, publicly funded programs prescribed fewer SUD medications than privately funded SUD treatment programs.

CONCLUSIONS

Patients seeking treatment in publicly funded treatment programs continue to face disparities in access to high-quality SUD treatment that supports patients' choices among a range of medication options. However, implementation of the Affordable Care Act may facilitate greater access to physicians and use of medications in publicly funded SUD treatment programs.

Patient characteristics and availability of onsite non-rapid and rapid HIV testing in US substance use disorder treatment programs

Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these caseload characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This study uses data collected in 2008-2009 from 198 program administrators of treatment programs participating in the National Institute on Drug Abuse's Clinical Trials Network to address this gap in the literature. Results show positive associations between the percentages of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapid HIV testing were more complicated. These findings suggest that many programs are responding to the needs of at-risk populations. However, programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

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.

Perceptions of the state policy environment and adoption of medications in the treatment of substance use disorders

OBJECTIVE

Despite growing interest in the use of evidence-based treatment practices for treating substance use disorders, adoption of medications by treatment programs remains modest. Drawing on resource dependence and institutional theory, this study examined the relationships between adoption of medications by treatment programs and their perceptions about the state policy environment.

METHODS

Data were collected through mailed surveys and telephone interviews with 250 administrators of publicly funded substance abuse treatment programs in the United States between 2009 and 2010. Multiple imputation and multivariate logistic regression were used to estimate the associations between perceptions of the state policy environment and the odds of adopting at least one medication for the treatment of substance use disorders.

RESULTS

A total of 91 (37%) programs reported having prescribed any medication for treatment of a substance use disorder. Programs were significantly more likely to have adopted at least one medication if they perceived greater support for medications by the Single State Agency. The odds of adoption were significantly greater if the program was aware that at least one medication was included on their state's Medicaid formulary and that state-contract funding permitted the purchase of medications.

CONCLUSIONS

States may play significant roles in promoting the adoption of medications, but adequate dissemination of information about state policies and priorities may be vital to further adoption. Future research should continue to study the relationships between the adoption of medications for treating substance use disorders and the evolving policy environment.

Barriers to the implementation of medication-assisted treatment for substance use disorders: the importance of funding policies and medical infrastructure

Despite growing interest in the use of evidence-based treatment practices, adoption of pharmacotherapies for treating substance use disorders (SUDs) remains modest. Using data from telephone interviews with 250 administrators of publicly funded SUD treatment programs, this study estimated a model of adoption of medication assisted treatment (MAT) for SUDs and examined the relative importance of regulatory, cultural, medical resource, patient-level, and funding barriers to MAT implementation. MAT-adopting programs had significantly greater medical resources, as measured by the employment of physicians and nurses, than non-adopting programs. Administrators of non-adopting programs were asked to rate the importance of 18 barriers to MAT implementation. The most strongly endorsed barriers were regulatory prohibitions due to the program's lack of medical staff, funding barriers to implementing MAT, and lack of access to medical personnel with expertise in delivering MAT. Barriers related to insufficient information about MAT and unsupportive staff attitudes were not widely endorsed. These findings suggest that efforts to promote the implementation of MAT that are inattentive to funding barriers and weaknesses in medical infrastructure may achieve sub-optimal results.

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.

A longitudinal examination of alcohol pharmacotherapy adoption in substance use disorder treatment programs: patterns of sustainability and discontinuation

OBJECTIVE

The objectives of this study were to (a) identify the patterns of disulfiram (Antabuse) and tablet naltrexone (Revia) adoption over a 48-month period in a nationally representative sample of privately funded programs that deliver substance use disorder treatment; (b) examine predictors of sustainability, later adoption, discontinuation, and nonadoption of disulfiram and tablet naltrexone; and (c) measure reasons for medication discontinuation.

METHOD

Two waves of data were collected via face-to-face structured interviews with 223 program administrators.

RESULTS

These data demonstrated that adoption of medications for alcohol use disorders (AUDs) was a dynamic process. Although nonadoption was the most common pattern, approximately 20% of programs sustained use of the AUD medications and 30% experienced organizational change in adoption over the study period. Bivariate multinomial logistic regression models revealed that organizational characteristics were associated with sustainability including location in a hospital setting, program size, accreditation, revenues from private insurance, referrals from the criminal justice system, number of medical staff, and use of selective serotonin reuptake inhibitors at baseline. Two patterns of discontinuation were found: Programs either discontinued use of all substance use disorder medications or replaced disulfiram/tablet naltrexone with a newer AUD medication.

CONCLUSIONS

These findings suggest that adoption of AUD medications may be positively affected by pressure from accreditation bodies, partnering with primary care physicians, medication-specific training for medical staff, greater availability of resources to cover the costs associated with prescribing AUD medications, and amending criminal justice contracts to include support for AUD medication use.

Using medication-assisted treatment for substance use disorders: evidence of barriers and facilitators of implementation

The use of medications to treat substance use disorders (SUDs) has emerged as a potentially central part of the treatment armamentarium. In this paper we present data from several recent US national surveys showing that despite the clinical promise of these medications, there has been limited adoption of pharmacotherapies in the treatment of SUDs. The data reveal variable patterns of use of disulfiram, buprenorphine, tablet naltrexone, acamprosate and injectable naltrexone. After examining the environmental and institutional context for the adoption of pharmacotherapies, the specific organizational facilitators and barriers of medication adoption are considered. The paper concludes with a discussion of the minimal clinical and administrative guidance available to enhance adoption, the lack of client and consumer knowledge of medications that puts a brake on their adoption and availability, and the difficulties that must be surmounted in bringing new medications to market.

Research to practice in addiction treatment: key terms and a field-driven model of technology transfer

The transfer of new technologies (e.g., evidence-based practices) into substance abuse treatment organizations often occurs long after they have been developed and shown to be effective. Transfer is slowed, in part, due to a lack of clear understanding about all that is needed to achieve full implementation of these technologies. Such misunderstanding is exacerbated by inconsistent terminology and overlapping models of an innovation, including its development and validation, dissemination to the public, and implementation or use in the field. For this reason, a workgroup of the Addiction Technology Transfer Center (ATTC) Network developed a field-driven conceptual model of the innovation process that more precisely defines relevant terms and concepts and integrates them into a comprehensive taxonomy. The proposed definitions and conceptual framework will allow for improved understanding and consensus regarding the distinct meaning and conceptual relationships between dimensions of the technology transfer process and accelerate the use of evidence-based practices.

Nurse turnover in substance abuse treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network

Voluntary nurse turnover, which is costly and disrupts patient care, has not been studied as an organizational phenomenon within substance abuse treatment organizations. In this exploratory study, we examined the frequency and correlates of nurse turnover within treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network. During face-to-face interviews conducted in 2005-2006, 215 program administrators reported the number of nurses currently employed. Leaders of programs with nursing staff then described the number of nurses who had voluntarily quit in the past year, the degree to which filling vacant nursing positions was difficult, and the average number of days to fill a vacant position. About two thirds of these programs had at least one nurse on staff. In programs with nurses, the average rate of voluntary turnover was 15.0%. Turnover was significantly lower in hospital-based programs and programs offering adolescent treatment but higher in facilities offering residential treatment. Most of the administrators indicated that filling vacant nurse positions was difficult and took more than 2 months to complete. These findings suggest that nurse turnover is a significant issue facing many substance abuse treatment facilities. Efforts to improve retention of the addiction treatment workforce should be expanded to include nursing professionals.

The adoption of alcohol pharmacotherapies in the Clinical Trials Network: the influence of research network participation

Organizational participation in clinical research may lead to adoption of the intervention by treatment agencies, but it is not known whether research involvement enhances innovativeness beyond the specific interventions that are tested. The National Institute on Drug Abuse's Clinical Trials Network (CTN) is a platform for considering this research question. To date, the CTN has not conducted research on medications for alcohol use disorders (AUDs), so greater adoption of innovative AUD pharmacotherapies by CTN-affiliated programs would suggest an added value of research network participation. Using longitudinal data from a pooled sample of CTN and non-CTN publicly funded treatment programs, we investigate adoption of tablet naltrexone and acamprosate over a 2-year period. CTN-affiliated programs were more likely to have adopted tablet naltrexone and acamprosate at 24-month follow-up, net of the effects of a range of organizational characteristics. Research network participation may thus enhance organizational innovativeness to include interventions beyond the scope of the network.