Lost in Translation:Understanding and Confronting the
Research to Practice Gap
Jack B. Stein, LCSW, Ph.D.Deputy Director
Division of Epidemiology, Services, and Prevention Research
National Institute on Drug Abuse
ASAM ConferenceMay 2006
Bringing the fullpower of Science to bear on…
Bringing the fullpower of Science to bear on…
Drug Abuse & Addiction Drug Abuse & Addiction
NIDANIDANIDANIDA
Priority Areas for NIDA
Treatment Interventions
Prevention Research (Children and Adolescents)
HIV/AIDS Research
Translation
% of Students Reporting Any Illicit Drug Use
(Past Year)
0
10
20
30
40
50
60
75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05
8th Grade 10th Grade 12th Grade
* Denotes significant difference
between recent peak year and current year.
*
*
*
% of High School Seniors Reporting Nonmedical Use of Sedatives
(Past Year)
0
2
4
6
8
10
91 92 93 94 95 96 97 98 99 00 01 02 03 04 05
12th Grade
* Denotes significant increase
2001-2005.
**
Prevalence of Drugs Among High School Seniors
Prevalence of Drugs Among High School Seniors
* Percentage reporting use in past year. **Nonmedical use.
Drug Prev.* Drug Prev.*Marijuana/Hashish 33.6 MDMA (Ecstasy) 3.0Vicodin** 9.5 Methamphetamine 2.5Amphetamines 8.6 "Ice" 2.3Sedatives** 7.2 Crack 1.9Tranquilizers** 6.8 LSD 1.8OxyContin** 5.5 Ketamine 1.6Cocaine (any form) 5.1 Steroid** 1.5Inhalants 5.0 PCP 1.3Cocaine Powder 4.5 Rohypnol 1.2Ritalin** 4.4 GHB 1.1
Methamphetamine:Our Next Drug Epidemic?
0
50000
100000
150000
200000
250000
300000
93 94 95 96 97 98 99 00 01 02 03
Primary Methamphetamine Admission Primary Cocaine Admissions
Primary Methamphetamine and Primary Cocaine Treatment Admissions
(1993 – 2003)
% of Primary Methamphetamine Treatment Admissions (Excluding Alcohol)
5.6
15.8
15.9
20.9
22.1
30.9
50.3
57.8
0 10 20 30 40 50 60 70
St. Louis
Atlanta
Seattle
Denver
Mpls./St. Paul
Los Angeles
San Diego
Hawaii
SOURCE: CEWG January 2006 reports on State and local data
What Research-Based Findings/Practices Most Need to
be Translated into Practice?
Neuroscience is revealing much about the brain and the relationship to addiction, relapse, and recovery
Addiction
DRUG
Environment
Biology/GenesBiology/
EnvironmentInteraction
Biological Factors Interact with Environmental Factors to Produce Addiction
Healthy Heart Diseased Heart
Decreased Heart Metabolism in Heart Disease PatientDecreased Heart Metabolism in Heart Disease Patient
Addiction is a Disease of the BrainAs other diseases, it affects tissue function
Control Cocaine Abuser
Decreased Brain Metabolism in Drug Abuse Patient
Sources: From the laboratories of Drs. N. Volkow and H. SchelbertSources: From the laboratories of Drs. N. Volkow and H. Schelbert
High
Low
3. Effective treatment should attend to multiple needs of the individual.
Intake Processing / Assessment
Treatment Plan
Pharmacotherapy
Continuing Care
Clinical and Case Management
Self-Help / Peer Support Groups
Behavioral Therapy and Counseling
Substance Use Monitoring
Detoxification
Child Care Services
Vocational Services
Medical Services
Educational ServicesAIDS / HIV
Services
Family Services
Financial Services
Legal Services
Mental Health Services
Housing / Transportation
Services
4. Recovery from drug addiction requires effective treatment followed by management of the disorder over time.
Substance Use Careers Last for Decades C
um
ula
tive
Su
rviv
al
Years from first use to 1+ years abstinence
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median duration of 27 years!
Scott & Dennis, (1998)
Treatment Careers Last for Years C
um
ula
tive
Su
rviv
al
Years from first Tx to 1+ years abstinence
2520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median duration of 9 years
and 3-4 episodes of care
Drug Dependence as a Chronic IllnessDrug Dependence as a Chronic Illness
Drug Drug DependenceDependence
Type I Type I DiabetesDiabetes
Hyper-Hyper-tensiontension
AsthmaAsthma
40 -
60%
40 -
60%
30 -
50%
30 -
50% 50
- 7
0%50
- 7
0%
50 -
70%
50 -
70%
Per
cen
t o
f P
atie
nts
Wh
o R
elap
seP
erce
nt
of
Pat
ien
ts W
ho
Rel
apse
O’Brien & McLellan, 1996, Lancet; McLellan et al. 2000, JAMA
ClinicalPractices
Initial Services
Engage & Sustain
TherapeuticInterventions
Assessment
•Prescription for Services
•Psychosocial Intervention (MI, MET, CBT, Contingency Mgt, CRT, 12-Step Facilitation, Structured Family/Couples)
•Pharmacotherapy
•Patient Engagement and Retention•Recovery/Chronic Care Management
•Screening •Initial brief Intervention
Chronic Disease Model
Recovery Management Checkup
• “Linkage Manager” who conducts motivational intervention and provides linkages
• Motivational Intervention:
- Provide personalized feedback
- Recognize problem and consider return to treatment
- Address existing barriers to treatment
- Schedule assessment
Dennis, Scott, Funk (2003)
720630540450360270180900
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
H1: RMC Clients will return to treatment sooner
Control (51% readmitted)
Days to Readmission
Percent to be R
eadmitted
OR: 1.34X2
(1)=6.8, p<.01
RMC(64% readmitted)
Median of 376 vs. 600 days, Wald=5.2,
p<.05
Median of 376 vs. 600 days
Dennis, Scott, Funk (2003).
5. Treatment must last long enough to produce stable behavioral changes.
55
28
53
1915
9
54
24
0
20
40
60
80
100
Cocaine (Any Use)*
UA+ (Any Drug)*
Alcohol (Daily Use)*
Any Jail*
< 90 Days 90+ Days
* p < .05 from Comparison
Aftercare MattersAftercare MattersAftercare MattersAftercare Matters
5
17
27
3529 28
55
69
0
20
40
60
80
100
No Tre
atm
ent
No Tre
atm
ent
CREST Dro
pouts
CREST Dro
pouts
CREST Com
plete
rs
CREST Com
plete
rs
CREST Com
plete
rs
CREST Com
plete
rs
+ Afte
rcar
e
+ Afte
rcar
e
*
*
**
*Drug-FreeDrug-Free Arrest-FreeArrest-Free
No Tre
atm
ent
No Tre
atm
ent
CREST Dro
pouts
CREST Dro
pouts
CREST Com
plete
rs
CREST Com
plete
rs
CREST Com
plete
rs
CREST Com
plete
rs
+ Afte
rcar
e
+ Afte
rcar
e
Martin, Butzin, Saum, & Inciardi (1999)
Delaware Correctional SystemDelaware Correctional System3 Years Post Work Release3 Years Post Work Release
7. Continuity of care is essential.
Medications to Keep an Eye On
• Topiramate: alcohol, cocaine, nicotine
• Marinol+rimonabant: marijuana
• Depot naltrexone: opiate, alcohol
• Bupropion, Vigabatrin, Topiramate, Modafinil: methamphetamine
11. Planning should include a focus on HIV/AIDS and other infections.
70 7465 62
26
11 1116 21
50
12 11 15 13 23
6 5 4 5 1
0%
20%
40%
60%
80%
100%
Population Lifetime Use Abuse/Depend.
Rec'd Tx IDUs w/ HIV-AIDS
White Black Hispanic Other
Expanded HIV Testing Improves Survival Rates and is Cost Effective
Paltiel, 2006; Sanders, 2006
Behavioral Treatments with Strong Scientific Support
• Medication Adherence
• Adolescent Treatments
• Cognitive-Behavioral Treatment
• Combined Pharmacotherapies and Behavioral Therapies
• Complementary and Alternative Treatments
• Community Reinforcement Approach
• Smoking Cessation
• Contingency Management Treatments
• Dialectical Behavioral Therapy
• Drug Counseling
• Family Treatments
• Group Behavior Therapy
• HIV Risk Reduction
• Motivational Interviewing/Enhancement
• Seeking Safety (PTSD)
• Work Therapy
Modafinil Improves CBT Therapy Results in Cocaine Addiction
Dackis, et al., 2006
A research infrastructure of 17 RRTCs & 150 CTPs across 34 States, and Puerto RicoA research infrastructure of 17 RRTCs & 150 CTPs across 34 States, and Puerto RicoA research infrastructure of 17 RRTCs & 150 CTPs across 34 States, and Puerto RicoA research infrastructure of 17 RRTCs & 150 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 Treatment Clinical Trials Network
NATIONAL INSTITUTE
ON DRUG ABUSE
NATIONAL INSTITUTE
ON DRUG ABUSENIDNIDAA
Drug Abuse Treatment Core Components and Drug Abuse Treatment Core Components and Comprehensive ServicesComprehensive Services
Child Care Services
Vocational Services
Mental Health Services
Medical Services
Educational Services
AIDS / HIV Risk Services
Family Services
Housing / Transportation
Services
Financial Services
Legal Services
Intake Processing / Assessment
Treatment Plan
Pharmacotherapy
Continuing Care
Self-Help (AA, NA) Meetings
Clinical & Case Management
Supportive Group and Individual Counseling
Substance Use & Urine Monitoring
Abstinence-Oriented Substance Abuse
Counseling
Motivational
Interviewing
Motivational
Incentives
Buprenorphine Detox
TELE
New CTN Protocols
• Health consequences of buprenorphine/naloxone and methadone
• Prescription Opioid Addiction Treatment
• ADHD and Substance Use Disorders
• 12-Step Facilitation
The Challenge of Implementation
Are We Speaking the Same Language?
• Technology Transfer
• Research Diffusion
• Dissemination
• Adoption
• Replication
• Implementation
• Science to Services
• Blending
A Conceptual Framework for Technology Transfer
Dissemination Adoption Implementation
An evidence-based program is one thing….
Implementation of an evidence-based practice is a very different
thing.
Bench Bedside Community
The Translation Bottleneck
00 2020 4040 6060 8080 100100
Senile cataractBreast cancerPrenatal care
Low back painCAD
HypertensionCongestive heart failureCerebrovascular disease
COPDDepression
Orthopedic conditionsOsteoarthritis
Colorectal cancerAsthma
Benign prostatic hyperplasiaHyperlipidemia
Diabetes mellitusHeadache
UTICommunity-acquired pneumonia
STDsDyspepsia and peptic ulcer disease
Atrial fibrillationHip fracture
Alcohol dependence
Senile cataractBreast cancerPrenatal care
Low back painCAD
HypertensionCongestive heart failureCerebrovascular disease
COPDDepression
Orthopedic conditionsOsteoarthritis
Colorectal cancerAsthma
Benign prostatic hyperplasiaHyperlipidemia
Diabetes mellitusHeadache
UTICommunity-acquired pneumonia
STDsDyspepsia and peptic ulcer disease
Atrial fibrillationHip fracture
Alcohol dependence
Quality of Health Care Delivery Quality of Health Care Delivery
Source: McGlynn, E.A., NEJM, 348, pp. 2635-2645, June 26, 2003Source: McGlynn, E.A., NEJM, 348, pp. 2635-2645, June 26, 2003
Adoption of Treatment Innovations
1.2%11.0%
25.6%
47.9%
29.7%
0%
10%
20%
30%
40%
50%
60%
BuprenorphineNaltrexone
Nicotine Patch
MET
Incentives
Percentage Currently Using Innovations
Roman, et al., Treatment Innovations in Publicly Funded Substance Abuse Treatment Centers: A Preliminary Report from the Field: Presentation at CTN Steering Committee Meeting, 2002.
(N = 171 Administrators)
• Off the shelf interventions often not readily accepted.
• May not work in real-life settings w/o modifications.
• Not enough attention to organizational/systems level issues.
• Plastic wrap on manuals often too tight to open.
Implementation Barriers
Implementation research is still limited
“We are faced with the paradox of non-evidenced based implementation of
evidence-based programs.”
-Drake, Gorman, & Torrey (2002)
Diffusion Theory
Everett Rogers
The QWERTY keyboard
Designed in 1873 to minimize jamming
The Dvorak Keyboard (1932)
Quicker to learnMore efficient
The “S” Curve
Time
% of Adoption
Early Adopters
Take-Off
Late AdoptersLarger farms
Higher incomesMore education
Source: Ryan & Gross (1943)
Adopter Categorization
x x+sdx-sdx-2sd
Innovators=2.5%
Early Adopters=13.5%
Early Majority=34% Late Majority=2.5%
Laggards=16%
Source: Rogers (2003)
Key Elements for Adoption of an Innovation
• Relative advantage
• Compatibility
• Complexity
• Trialability
• Observability
“…the best candidate for rapid adoption would be an evidence-based treatment that
was simple, was similar with previous practice, had clear advantage, could be tried
out temporarily, and was readily observable.”
-Henggeler, Lee, & Burns (2002) Clinical Psychology-Science and Practice
Early Technology Transfer Research at NIDA
• “Reviewing the Behavioral Science Knowledge Base on Technology Transfer”
• Monograph Number 155 (Backer, David, & Soucy, 1995)
Bridging the Gap
• Community treatment providers should be more involved in research
• More effective dissemination and training strategies
• More knowledge needed about how technology transfer actually occurs
• Organizational and economic factors need to be considered
Institute of Medicine (1998)
At the Louis de la Parte Florida Mental Health Institute
University of South Florida
http://nirn.fmhi.usf.edu
Implementation:What Doesn’t Work
• Information dissemination alone (research literature, mailings, promulgation of practice guidelines)
• Training alone (<10% transferred)
OUTCOMES
TRAININGCOMPONENTS
KnowledgeSkill
DemonstrationUse in the Classroom
Theory and Discussion
10%
5% 0%
+Demonstration in Training
30%20%
0%
+ Practice & Feedback in Training
60% 60% 5%
+Coaching in Classroom
95% 95% 95%
Joyce and Showers, 2002
Training Components and Implementation
Effective Intervention Practices
EffectiveImplementation Practices
Good Patient Outcomes
+
Formula for Successful Patient Outcomes
Practitioner
Evidence-based Practices
Purveyor
Fidelity & OutcomeMeasures
Implementation Framework
Organizational Structures/Culture
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
?
PractitionerSystem of carePolicy makers
• Exploration
• Installation
• Initial Implementation
• Full Implementation
• Innovation
• Sustainability
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
2 – 4 Years
Stages of Implementation
ProgramProgramImprove-Improve-
mentment
ProgramProgramImprove-Improve-
mentment
Stages of TransferStages of TransferStages of TransferStages of Transfer1-Exposure1-Exposure ((TrainingTraining))
• LectureLecture• Self StudySelf Study• WorkshopWorkshop• ConsultantConsultant
1-Exposure1-Exposure ((TrainingTraining))
• LectureLecture• Self StudySelf Study• WorkshopWorkshop• ConsultantConsultant
TCU Program Change Model
ProgramProgramChangeChange
ProgramProgramChangeChange
Organizational DynamicsOrganizational Dynamics
Institutional & Institutional & Personal ReadinessPersonal Readiness
StaffStaffStaffStaff 2-Adoption2-Adoption(Leadership decision)(Leadership decision)2-Adoption2-Adoption(Leadership decision)(Leadership decision)
4-Practice4-Practice(Routine use)(Routine use)4-Practice4-Practice(Routine use)(Routine use)
3-Implementation3-Implementation(Exploratory use)(Exploratory use)3-Implementation3-Implementation(Exploratory use)(Exploratory use)
ResourcesResourcesResourcesResourcesMotivationMotivationMotivationMotivation
ClimateClimatefor Changefor Change
ClimateClimatefor Changefor Change
StaffStaffAttributesAttributes
StaffStaffAttributesAttributes
Source: Simpson (2002)
A Comprehensive Framework for Research Implementation
ClinicalPractices
ProgramComponents
Systemic FactorsFinancial
Health CareInfrastructure
Legal/Regulatory
Education &Training
Research & KnowledgeTransfer
Org Structure& Culture
PatientEngagement
Staffing
Info &Clinical
Care Systems
Initial Services
Engage &Sustain
TherapeuticInterventions
Assessment
National Quality Forum (2005)
Washington Circlewww.washingtoncircle.org
• A policy group on performance measurement for care of substance abuse dependence
• 4 domains of care
• 7 core performance measures
• 3 adopted by National Committee for Quality Assurance’s (NCQA) Health Plan Employer Data and Information Set (HEDIS)
Domain Measure
Prevention/Education Educating patient about AOD disorders
Recognition *Identification rates
Treatment *Initiation of AOD plan services
Linkage of detox and services
*Treatment engagement
Interventions for family/significant others
Maintenance Maintenance of treatment effects
Washington Circle Performance Measures
* HEDIS measure
Science to Services Activities Underway:
Research Opportunities
Blending Teams:Linkages Between CTN and ATTC
Philadelphia
Portland
Los Angeles
Charleston
Miami
Cincinnati
Denver
CTN Sites
Seattle
Raleigh/Durham
ATTC
Puerto Rico ATTC
Long Island
Boston
San Francisco (CA/AZ Node)
New York City
Detroit
Albuquerque
Baltimore/Richmond
New Haven
Training Rural Practitioners to Use Buprenorphine:Using The Change Book to Facilitate Technology Transfer
• 7 multi-disciplinary Oregon county teams convened using The Change Book model
• N = 51 (17 MD’s, 4 pharmacists, 2 nurses, 28 drug counselors)
• 1.5 day training
• Significant improvements in attitudes based on pre/post testing
• 8 months after training, 10 of 17 MDs received waivers to use buprenorphine
Source: McCarty et al (in press)
NIDANIDANATIONAL INSTITUTE
ON DRUG ABUSENATIONAL INSTITUTE
ON DRUG ABUSE
www.drugabuse.gov
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