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Trends in Adoption of Medications for Alcohol

DependenceLori J. Ducharme, J. Aaron Johnson, Hannah K.

Knudsen & Paul M. Roman

University of Georgiawww.uga.edu/ntcs

Supported by NIAAA Grant R01DA10130 and NIDA Grants R01DA13110 and R01DA14487

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Medications in Alcohol Treatment

• Substantial attention paid to the “research-to-practice gap” in addiction treatment

• Several medications are available or in the pipeline for alcoholism treatment

• What are the factors that predict adoption and use of medications by addiction treatment programs?

• What are the implications for diffusion of these treatment technologies?

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Diffusion of Innovations• Innovations = new to the adopter• Rogers (1995) suggests several factors central

to innovation diffusion:– Compatibility – “fit” with org structure, resources,

practices, and philosophy– Trialability – can “test” the technology without full

commitment up front– Observability – can readily see results – Relative Advantage – better than what’s otherwise

available– Complexity – can be learned easily; can be integrated

without wholesale restructuring

• Diffusion is a process, but often measured as a discrete event

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Objectives• Describe trends in adoption of disulfiram and

naltrexone in the private sector, 1994-2004– SSRIs shown as point of reference for same period

• Describe current patterns of use of these medications in public vs private sectors, 2004

• Identify predictors of medication use, and barriers to adoption

• Examine counselor attitudes & receptivity• Suggest implications for recently-approved

medications (acamprosate)

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Data Sources

1. Panel data on N=252 private-sector addiction treatment facilities, 1994-2004

2. Cross-sectional data on N=403 private-sector and N=362 public-sector treatment facilities, 2004

3. Cross-sectional data on N=2,200 counselors in these programs, 2004

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Private Sector Data, 1994-2004

Any Use of Medication in Program1995 2000 2004

Disulfiram 51.6% 50.4% 35.7%

Naltrexone 49.2% 45.2% 41.7%

SSRIs 77.0% 73.4% 68.3%

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Patterns of Adoption are Unstable Over Time

Disulfiram Naltrexone

SSRIs

Adopted + kept

32.1% 35.7% 59.1%

Tried + dropped

37.7% 30.6% 26.2%

Never tried 26.6% 27.8% 5.6%

Inconsistent 3.6% 6.0% 9.1%

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Predictors of Adoption

• Greater reliance on private insurance and self-paying clients increased likelihood of using naltrexone or disulfiram at some point

• No clear predictors of “keepers”• SSRIs as “gateway drug” – programs

that don’t adopt SSRIs are unlikely to adopt other medications

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• Panel data suggest overall low (and declining) adoption and implementation in the private sector.

• How does the public sector differ?• Why should funding source matter?

– Private insurance may be more likely to reimburse for medications, which represent a cost efficient technology.

– We differentiate nonprofit sector by primary revenue source (majority public funds vs majority private funds)

Integrating Data from the Public Sector

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Adoption, by Sector, 2004% programs reporting any use of

medication

0

20

40

60

80

100

Overall For Profit Priv NP Pub NP Govt

DisulfiramNaltrexoneSSRIs

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Implementation Rates% alcohol clients receiving meds,

2004

% primary alcohol patients receiving med

All centers in sample

For Profit

Private NP

Public NP

Gov’t owned

Disulfiram 11.2 10.6 10.9 11.8 12.1

Naltrexone

8.8 12.1 8.7 6.6 6.7

SSRIs 58.0 62.9 61.7 48.8 54.9

Note: “public” and “private” refer to principal revenue sources, not

ownership

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Adoption: Organizational Correlates

(bivariate tests)Org structure:Hospital based (+)Inpatient only (-)Dual diagnosis enhanced (+)% Master’s level counselors (+)Physicians on staff (+)

External stakeholders:Accredited (+)% public revenues (-)Legal system referrals (-)

Org philosophy:% recovering staff (-)Admin has medical background (+)

Patient characteristics:% primary alcohol (+)Total admissions (+)

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Adoption Predictors(multivariate logistic

regressions)• Disulfiram: physicians (+), hospital (+), public

funded nonprofits (-), dual dx enhanced (+)

• Naltrexone: privately funded (+), accredited (+), dual dx enhanced (+), physicians (+), % masters counselors (+)

• SSRIs: physicians (+), public nonprofits (-), accredited (+), dual dx enhanced (+), % relapsers (+), legal system referrals (-), % masters counselors (+)

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Barriers to Adoption

Administrators were asked, To what extent are these factors reasons for not using [medication]?

(Shown: Percent responding “very much” /

“extremely”)Disulfiram Naltrexone

Inconsistent w/ tx philosophy

53% 39.5%

Better alternatives available 40.7% 22%

No medical personnel 37% 37.5%

Staff resistance 17.6% 11.5%

Cost / reimbursement issues

9.8% 12.1%

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A Look at Staff AttitudesSurveys of Counseling Staff, 2004

“Don’t Know” Effectiveness

Acceptability Score (1-7)

Disulfiram 19.4% 3.70

Naltrexone 39.7% 4.18

SSRIs 31.9% 4.81

• For reference: 17% DK methadone, 61.6% DK buprenorphine, 85.9% DK acamprosate

• Perceptions increased with: extent of use at program; educational level; tenure in addiction treatment field

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Conclusions / Implications• Use of disulfiram and naltrexone are low, and

declining over time– Use is significantly higher among programs relying

on private insurance & self-pays

• Medications appear to fail on “compatibility” factors– Program philosophy is a significant barrier– Medical staff availability is key– However, SSRIs are more widely used (more

complete medicalization of psychiatric conditions?)

• Awareness of acamprosate is extremely low; adoption bears monitoring over time– How does program/staff experience with other meds

affect willingness to use acamprosate?