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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