The CTN Research Utilization Committee: Putting Dissemination Research into Practice Jeffrey Selzer, MD Chair, CTN Research Utilization Committee Long.

The CTN Research Utilization Committee: Putting

Dissemination Research into Practice

Jeffrey Selzer, MD

Chair, CTN Research Utilization Committee

Long Island Regional Node, CTN

North Shore-Long Island Jewish Health System

Albert Einstein College of Medicine

A research infrastructure of 16 RRTCs & 240 CTPs across 34 States, and Puerto RicoA research infrastructure of 16 RRTCs & 240 CTPs across 34 States, and Puerto RicoA research infrastructure of 16 RRTCs & 240 CTPs across 34 States, and Puerto RicoA research infrastructure of 16 RRTCs & 240 CTPs across 34 States, and Puerto Rico

Oregon NodeOregon NodeOHSUOHSU

Washington NodeWashington NodeU. WashingtonU. Washington

Pacific NodePacific NodeUCLAUCLA

Florida NodeFlorida NodeU. MiamiU. Miami

Tri stateTri stateU. PittsburghU. PittsburghOhio Valley NodeOhio Valley Node

U. CincinnatiU. Cincinnati

South Carolina NodeSouth Carolina NodeMUSCMUSC

North Carolina NodeNorth Carolina NodeDukeDuke

California/Arizona NodeCalifornia/Arizona NodeUCSF/U. ArizonaUCSF/U. Arizona

Southwest NodeSouthwest NodeU. New MexicoU. New Mexico

Northern NE NodeNorthern NE NodeMcLean/HarvardMcLean/Harvard

California/Arizona NodeCalifornia/Arizona NodeUCSF/U. ArizonaUCSF/U. Arizona

Southwest NodeSouthwest NodeU. New MexicoU. New Mexico

Northern NE NodeNorthern NE NodeMcLean/HarvardMcLean/Harvard

New England NodeNew England NodeYaleYaleNew York NodeNew York Node

NYUNYULong Island NodeLong Island Node

NY State Psych. Inst.NY State Psych. Inst.

Delaware Valley NodeDelaware Valley NodeU. PennsylvaniaU. Pennsylvania

MidMid--Atlantic NodeAtlantic NodeJHU/MCVJHU/MCV

Texas NodeTexas NodeUT SouthwesternUT Southwestern

National Drug Abuse TreatmentNational Drug Abuse TreatmentClinical Trials NetworkClinical Trials Network

Missions of the CTN: A.   Conduct studies of behavioral, pharmacological and

integrated behavioral and pharmacological treatment interventions in rigorous, multi-site clinical trials to determine effectiveness across a broad range of community based treatment settings and diversified patient populations.

B.   Timely transfer of the research results to clinicians, providers, their patients and the policy makers to improve the quality of drug abuse treatment throughout the country using science as the vehicle.

CTN strategic plan includes the importance of using the CTN as an infrastructure to study best approaches to disseminating treatment innovations.

Pending, Pending, Development & Development &

ReviewReview

Pending, Pending, Development & Development &

ReviewReview

Recruitment & Recruitment & Data Data

CollectionCollection

Recruitment & Recruitment & Data Data

CollectionCollectionFollow-UpFollow-UpFollow-UpFollow-Up

Data Analysis, Data Analysis, Publication, & Publication, & DisseminationDissemination

Data Analysis, Data Analysis, Publication, & Publication, & DisseminationDissemination

CTN 0027CTN 0028CTN 0029CTN 0030

CTN 0027CTN 0028CTN 0029CTN 0030

CTN 0014CTN 0014 CTN 0001CTN 0002CTN 0003CTN 0004CTN 0005CTN 0006CTN 0007CTN 0008CTN 0009CTN 0010CTN 0011CTN 0012CTN 0013CTN 0015CTN 0016CTN 0017CTN 0018CTN 0019CTN 0020CTN 0021

CTN 0001CTN 0002CTN 0003CTN 0004CTN 0005CTN 0006CTN 0007CTN 0008CTN 0009CTN 0010CTN 0011CTN 0012CTN 0013CTN 0015CTN 0016CTN 0017CTN 0018CTN 0019CTN 0020CTN 0021

CTN 0022CTN 0023CTN 0024CTN 0025CTN 0026CTN 0031CTN 0032

CTN 0022CTN 0023CTN 0024CTN 0025CTN 0026CTN 0031CTN 0032

The CTN Trials (1999 – now)The CTN Trials (1999 – now)

Medical Interventions: 9Behavior Interventions: 11HIV/HCV Interventions: 4Others: 3

Medical Interventions: 9Behavior Interventions: 11HIV/HCV Interventions: 4Others: 3

“I utilize the best from Freud, the best from Jung, and the best from my Uncle Marty, a very smart fellow.”

Patient Outcomes

Effective intervention practices

+Effective implementation practices

=

Good outcomes for Patients

Characteristics of an Innovation Which Is Most Easily Disseminated

(Everett Rogers, 2003):1. Confers a relative advantage compared with the current practice

2. Is compatible with other current practices

3. Is relatively simple to learn and implement

4. May be tried before making a commitment to adoption

5. Positive results are observable by the adopter

When innovations are adopted, “reinvention is inevitable.”

Widely Used Dissemination Approaches:

1. Conference presentations2. Workshops3. Distribution of printed manuals4. Performance feedback which does not occur in real-time

None of these commonly used approaches has been demonstrated to effectively promote dissemination of innovations .

Effective Strategy For Implementing a New Intervention

Three-step process– Provide opportunities to acquire basic knowledge

about intervention– Provide opportunities for practice with feedback– Provide expert coaching to improve performance

Not dissimilar from how interventions in research protocols are implemented (i.e., training with fidelity monitoring)

Conclusions reached by the RUC:

• Implementation of interventions throughout the CTN would require ongoing technical assistance (i.e., coaching)

• For implementation to occur, “maintenance was as important sales.”

Blending Initiative Initiative

• SAMHSA-NIDA Collaboration through ATTCsSAMHSA-NIDA Collaboration through ATTCs• BlendingTeam members include NIDA researchers

on a given intervention, community treatment programs with experience using the intervention, and Addiction Technology Transfer Center staff

• Blending products (Blending products (designed to promote adoptiondesigned to promote adoption): ): → Buprenorphine Awareness → Short-Term Opioid Withdrawal Using

Buprenorphine: Findings and strategies*→ SMART Treatment Planning: Utilizing the ASI→ MI Assessment: Supervisory Tools for

Enhancing Proficiency*→ Promoting Awareness of Motivational

Incentives* *Based on CTN Studies

CTN Research Utilization Workgroups:

• Motivational Interviewing

• Buprenorphine Treatment

• Motivational Incentives(Selection of interventions based on CTP

needs and by availability of Blending Products. Opportunity to “kick the tires” on the Blending Products.)

CTN Motivational Interviewing TrialCTN Motivational Interviewing Trial

• Patients (n=423) assigned to MI at intake subsequently completed more counseling sessions (mean=5.02, sd=5.15) than Standard Care patients (mean=4.03, sd=4.21) during 28 days after randomization (p<.05)

• MI patients more likely (84%) to still be enrolled at the program after one month than Standard Care patients (75%) (p<.04)

Agreement about Occurrence

M

I

A

STEP

MotivationalInterviewingAssessment:

Supervisory Tools forEnhancing Proficiency

MIA: STEP is…

– A multi-media tool kit for enhancing MI proficiency in clinicians already knowledgeable about MI (“The last thing we need is another MI training manual.” Bill Miller)

– A resource for supervisors to help them become more effective supervisors

– A supervisory model which emphasizes fidelity to the intervention and bringing actual clinical material into supervision

16 Rating ItemsMI Consistent • MI Style or Spirit

• Open-ended Questions

• Affirmations

• Reflections

• Fostering Collaboration

• Motivation to Change

• Developing Discrepancies

• Pros, Cons, and Ambivalence

• Change Planning Discussion

• Client-centered Feedback

MI Inconsistent

• Unsolicited Advice

• Emphasize Abstinence

• Direct Confrontation

• Powerlessness/Loss of Control

• Asserting Authority

• Closed-ended Questions

Motivational Interviewing Workgroup:

Bill Miller (Researcher who developed MI)

Steve Martino (Researcher in CTN MI study)

Steve Gallon (ATTC Director) Chris Farentinos (CTP Representative)

Train-the-Trainer in Use of the Blending Product

• Applicants from CTN Nodes and ATTCs had to first demonstrate MI proficiency using the MITI system.

• 51 applicants + 3 MIA: STEP trainers • 1/3 of the applicants were unable to demonstrate

MI proficiency in the first round • 26 passed from CTN/18 passed from ATTC by

the second round • Trained 42 individuals as MIA: STEP trainers

Training

• 2.5 days in Kansas City – sponsored by the ATTC National Office

• Product overview

• Step-by-step experiential walk-through of MIA: STEP

• Discussion of implementation issues

Roll-outs completed• Prince William County Community Services Board,

Virginia N = 17

• North Carolina Alcohol Drug Abuse Treatment Centers

N = 39

– Included psychiatrists, medical doctors, nurses, recreational therapists, SA counselors, social workers at three sites

• Hawaii State Providers N = 25

• ChangePoint, Oregon N = 5

• Baltimore, Maryland N = 6

Roll-outs completed

• Miami-Dade County/South Florida Provider Coalition, 240 supervisors trained

• 100 hardcopies with CDs have been distributed; NFATTC and Mid-Atlantic ATTC both have 200 copies.

• http://www.motivationalinterview.org/library/MIA-STEP.pdf is averaging 12,000 downloads per week!

Implementation Considerations

• MI training prerequisites• Individual vs. group supervision• Frequency• Setting-specific modifications• Agency support• State support• Curriculum/On-going consultations (CEUs)

• Support to train MIA: STEP

Where do we go from here?• Listserv – Mid-Atlantic ATTC?

• Ongoing technical assistance for trainers, including more practice sessions/co-ratings?

• Quarterly conference calls open to trainers and supervisors?

• Obligations of trainers and $ to support them?

• Annual training of trainers or link training to Blending Conference

• MI Proficiency standards: MITI or MIA: STEP and with what support?

• Establish point person for ATTC (Gallon?) and CTN (Martino?)

• How to monitor effectiveness of strategy?

What is missing?

99% = Investment in Intervention Research to develop solutions

1% = Investment in Implementation Research to make effective use of those solutions (Up from ¼% in 1977)

Implementation Research Underway in the CTN

• 7 Nodes• 12 Studies underway• Interventions: Motivational Interviewing; CBT;

TSF; Motivational Incentives; Process Improvement Strategies

• Implementation variables: role of fidelity measures; cultural adaptations; Web-based and interactive CD Rom-based training; factors promoting adoption after the end of CTN trials

Many thanks for your attention!