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Editor’s Note: This article was adapted from an article that ran in the Journal of Substance Abuse Treatment (JSAT), in accordance with a partnership agreement between Counselor Magazine and JSAT, to bridge the gap between research and clinical practice in the addiction field.
Research is steadily advancing our understanding of substance use disorders, and is spawning ever more effective treatments; however, it often takes several years for therapies with demonstrated efficacy to enter clinical practice (Lamb, Greenlick & McCarty, 1998). As a result, patients are slow to experience the benefits of cutting-edge addiction research. This delay is due largely to the many challenges involved in moving new technologies from the research lab into widespread use.
This process, broadly referred to as “technology transfer,” involves numerous stakeholders, each with unique strengths, resources, needs and expectations that must be coordinated and satisfied for transfer to occur. To accelerate the development and adoption of new addiction treatments, the National Institute on Drug Abuse (NIDA) in 2001, launched the Blending Initiative, a wide-ranging effort that combines and coordinates the knowledge, skills and resources of researchers, treatment providers, policy makers and technology dissemination programs; and in doing so, removes many of the obstacles that commonly impede technology transfer.
Technology transfer
The drive to innovate seems to be an innate feature of human nature; indeed, humans have always created new technologies to reduce labor and discomfort, as well as to be more efficient and productive. Given this propensity, it is surprising that it was nearly the mid-20th century before serious attempts were made to formalize the innovation process and apply it on a large scale. As expected, the strategies used in these initial efforts accorded with that era’s view of technology transfer which assumed that: discoveries made in research laboratories would more or less spontaneously “bubble up” into the hands of potential users; potential users would immediately recognize the intrinsic value of these discoveries; potential users possessed the know-how and resources to use these innovations as intended; and research findings could be disseminated quickly to the broader community of potential users simply by publishing study results in professional journals (i.e. passive dissemination) (T.E. Backer, 2000; T.E. Backer, David, & Souly, 1995). Accordingly, the “diffusion of innovation” has been driven primarily by the publication of research and consensus conference findings in peer-reviewed journals (T.E. Backer, 2000; T.E. Backer et al., 1995).
Since then, however, research and experience have revealed that the transfer of technologies from development to application is anything but spontaneous (Rogers, 2003); indeed, improving the human condition through the purposeful application of technology is an intricate and difficult process which, to succeed, must satisfy several interdependent conditions (ATTC, 2004; T.E. Backer, 2000). Not surprisingly then, traditional technology transfer efforts, independent of the particular knowledge or innovation conveyed, often fail to produce significant and enduring change, even when coupled with user training (ATTC, 2004; Brown & Flynn, 2002).
Unfortunately, the addiction research and treatment enterprise is not immune to these difficulties—several factors can, and often do, slow the adoption of new interventions (Lamb et al., 1998). First, many people inside and outside the world of addiction research and treatment still maintain—despite incontrovertible evidence to the contrary—that addiction is a failing of morality and discipline, rather than a brain disorder. This view tends to undermine the adoption of interventions that address biological rather than moral aspects of addiction. Second, the study and treatment of addiction has not come of age in the context of the medical model in which clinical practice is largely research driven, and the adoption of evidence based therapies is routine. Third, the addiction research and treatment enterprise has relied primarily on ineffective research dissemination strategies (e.g., the publication of study findings in science journals). Fourth, treatment providers often lack the financial, physical and human resources needed to implement a new therapy as it is intended to be, and it may not be clear to what extent a particular therapy can be modified to accommodate available resources and retain a clinically significant effect.
Several workforce issues also are slowing the adoption of new addiction interventions. Foremost among these is the tendency of individuals and organizations to resist change (ATTC, 2004; Diamond, 1995). Such resistance creates a formidable psychological barrier to the adoption of new ideas and practices. For example, a community treatment provider may resist adopting an effective therapy because it contradicts its institutional treatment philosophy and its assumptions regarding the causes and treatment of addiction. Implementing evidence-based addiction interventions will therefore require some individuals and organizations to modify their existing treatment philosophies and behaviors or acquire new ones (T.E. Backer, 1995). Fortunately, individuals’ and organizations’ readiness for change can be enhanced by promoting recognition of technology transfer as change, and including activities in the transfer process that address feelings, attitudes and beliefs regarding change (T.E. Backer, 1995; Diamond, 1995).
The disciplinary diversity of the addiction treatment workforce also can work against the adoption of new interventions. Addiction treatment is administered by an array of professionals, including: psychiatrists, medical addiction specialists, clinical psychologists, nurses, family therapists and drug and marriage counselors. This diversity is one of the strengths of the U.S. healthcare system, but differences in practitioners’ education, training and experience also make it difficult to address the field broadly and foster systemic change. For example, drug counselors are the front line of substance abuse treatment, and as such, have often been the targets of efforts to incorporate addiction research into practice. Because of differences in education, however, some counselors may be less prepared to make desired changes (Simpson, 2002). Additionally, high
stress and low compensation have produced high rates of job burnout among counselors (Simpson, 2002); thus, advances in treatment that do gain a foothold in practice are likely to be lost as the result of worker turnover.
The Blending Initiative
To overcome these obstacles and accelerate the transfer of addiction research into clinical practice, NIDA, in 2001, launched the Blending Initiative. In part, a collaboration with Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Substance Abuse and Treatment’s (CSAT) Addiction Treatment Transfer Center (ATTC) program, the Blending Initiative is a multi-dimensional effort that “blends” the complementary knowledge, skills and resources of addiction researchers, treatment providers, policymakers and technology dissemination programs into a highly interactive and dynamic collaboration. This collaboration more fully integrates all the various stakeholders into the development and implementation of evidence-based treatment practices.
In its design and development, the Blending Initiative owes much to the work of Everett Rogers. A pioneer in the field of innovation diffusion, Rogers formalized the influential Diffusion of Innovations (DOI) theory, and for more than 40 years, elaborated on the DOI framework, expanding its application to numerous and diverse contexts including health care and substance abuse (Rogers, 2003). The Blending Initiative has been particularly influenced by the following observations and principles defined and organized by Rogers: the diffusion of innovation is a dynamic social process that “flows” through interpersonal networks; the adoption and implementation of innovations is strongly influenced by “opinion leaders” within these networks; end-users participate actively in adopting and implementing innovation; and end-users frequently modify or “re-invent” innovations to better suit their local needs and capabilities.
The Blending Initiative process begins with the identification of promising research that fills a gap in addiction treatment. These findings are gleaned from trials conducted by NIDA’s Clinical Trials Network (CTN) and other NIDA-sponsored investigations. The CTN, which has 17 regional research and training centers, evaluates the “real-world” effectiveness of drug abuse interventions by conducting clinical trials in diverse community treatment settings with diverse patient populations. The outcomes of these trials are forwarded to a group of researchers and practitioners who participated in the studies; the research is reviewed and its potential for “real-world” application is evaluated. A “blending team” comprised of three NIDA representatives and three ATTC representatives is formed for each research protocol deemed ready for widespread adoption. The ATTC is a network of 14 regional offices and a national office that monitors, translates, and disseminates advances in addiction research. The ATTC also provides treatment professionals with training and assistance to enhance their skills accordingly. These steps in the process are primarily NIDA-driven.
In the next, largely SAMHSA-driven, part of the process, each blending team designs a dissemination plan and develops the materials and activities needed to support adoption of the new practice. Every effort is made to release dissemination products as close as possible to the publication of the relevant research.
Blending teams and dissemination products
To date, five separate blending projects have been launched, and the following dissemination/training materials have been developed:
1. Short-term Opioid Withdrawal Using Buprenorphine;
2. Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals;
3. Treatment Planning M.A.T.R.S.: Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful;
4. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency
(MIA-STEP); and
5. Promoting Awareness of Motivational Incentives (PAMI).
Short-term Opioid Withdrawal Using Buprenorphine. Clonidine has frequently been used to help detoxify opioid-dependent patients (Gowing & Ali, 2006). CTN-sponsored trials conducted in several community treatment programs, however, have shown that more patients following a 13-day tapered buprenorphine detoxification protocol were able to provide an opioid-negative urine sample at the end of the taper, compared to the group receiving clonidine (Ling et al., 2005).
Accordingly, this blending team was charged with creating training materials to inform treatment providers about the detoxification protocol and instruct them in its use. The resulting training package, which is complete and now available, characterizes opiate withdrawal and discusses the rationale for providing detoxification for opioid-dependent individuals; the goals of detoxification; the management of withdrawal symptoms; the risks of overdose following detoxification; and the implementation of the protocol in treatment settings.
Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals. Another buprenorphine blending team was formed and charged with creating materials to increase addiction professionals’ (non-physician) awareness of buprenorphine treatment. The resulting training package entitled Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals, is available and provides classroom training and self-paced CD-ROM buprenorphine awareness courses as well as research articles and an annotated bibliography. These materials also provide information regarding a variety of relevant legislative, counseling and therapeutic issues.
Treatment Planning M.A.T.R.S.: Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful. Addiction treatment professionals working in community-based settings often view the Addiction Severity Index (ASI)—a widely administered but under-utilized client assessment tool—as unnecessary paperwork of little clinical value. To promote and facilitate increased clinical use of ASI findings, a blending team was created to develop training materials that demonstrate how ASI information can assist in client evaluation and individualized treatment planning that emphasizes the development of measurable, attainable, time-limited, realistic and specific (M.A.T.R.S.) objectives and interventions. These training materials are now available and include both 6-hour classroom and 4-week online training programs.
Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA-STEP). Motivational Interviewing (MI) is a brief behavioral intervention designed to enhance substance abusers’ intrinsic motivation and capacity for change. A CTN-sponsored randomized clinical trial conducted at five CTN-associated community treatment centers evaluated the effect on retention and substance abuse outcomes of the incorporation of MI into a standard intake and evaluation session. This study reported that MI strategies delivered within a single 60-minute session resulted in higher retention rates and a significant increase in the number of sessions completed during the first 28 days of treatment, compared to standard intervention. MI, however, had no significant effects on substance use outcomes at either the 28-day or 84-day follow-up (Carroll et al., 2006). Results of this study suggest that, with proper training and supervision, community treatment providers can effectively implement MI techniques and that integrating MI techniques into only a single initial evaluation session may increase retention in the early phases of treatment. Another study reported that six months after meeting with a peer addiction educator during a routine medical care visit, patients who participated in a motivational interview had higher rates of abstinence than patients who received treatment sources list only (Bernstein et al., 2005). Thus, even a brief encounter with a peer educator utilizing MI strategies can motivate drug abstinence.
The Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA-STEP) training materials have been developed and are now available. This product enhances treatment providers’ motivational interviewing skills and the ability of supervisors to provide more structured and focused supervision. These materials—which include a 10-hour supervisor training curriculum, a supervisor tape-rating guide and demonstration materials—provide supervisors with tools to teach, assess and improve counselors’ MI techniques and skills.
Promoting Awareness of Motivational Incentives (PAMI). Contingency management interventions—such as the awarding of prizes, additional clinic privileges and vouchers redeemable for goods and services—aim to modify substance abuse behaviors by positively reinforcing objective indicators of drug abstinence (e.g. drug-free urine samples). Several studies have demonstrated that motivational incentives increase patient retention and reduce substance use. Indeed, CTN-sponsored multi-site studies conducted in community-based treatment settings and evaluating the efficacy of contingency management interventions as an addition to usual care reported that over 12 weeks, participants receiving abstinence incentives were significantly more likely to submit negative samples than those receiving usual care (at six month follow-up no significant differences were found) (Peirce et al., 2006); and that use of contingency strategies in these treatment settings improved patient retention and drug abstinence (Petry et al., 2005). Despite their efficacy, however, contingency strategies have not been widely adopted in community-based treatment settings.
To address this issue, a Promoting Awareness of Motivational Incentives (PAMI) blending team was formed and charged with creating training materials that increase awareness of motivational incentives and incorporate examples of successful approaches in the use of motivational incentives from the Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR) CTN protocol. These materials are now available and include a training video, PowerPoint presentation, brochure, CD of resources, research fact sheet and bibliography.
Additional NIDA blending activities
While the Blending Initiative itself is new, it is consistent with NIDA’s long history of collaborations with agencies outside the NIH. These collaborations range from informal consultations to jointly sponsored research programs such as the NIH/SAMHSA “Science to Services Workgroup” established in 2002. These collaborations are sometimes made more formal by linking funding streams. For example, the linking of NIDA and SAMHSA funding to support implementation of NIDA-funded research protocols in the delivery of SAMHSA-funded services activities. Linking funding streams maximizes each agency’s resources and is allowing NMIDA to ask important services research questions in a cost-effective manner.
The most visible of NIDA’s “blending” activities is the annual Blending Conference. These popular meetings bring researchers and treatment providers together and encourage them to exchange knowledge, experiences and information. The meetings are co-organized with a CTN node and tailored to the specific interests of that region. The meetings include plenary sessions with renowned speakers and workshops led by researchers and providers who discuss the research supporting particular practices, and how these practices have been implemented in particular settings. NIDA also participates in regional and national meetings of State drug abuse agencies with whom it has partnered to enhance the adoption of drug research, and disseminates addiction research and up-to-date drug abuse information via numerous print and Web-based publications that are available on its website.
Over the last 35 years, neuroscientists have made tremendous progress in understanding the biology of the brain. This research has provided incontrovertible evidence that drug addiction is a neurologic disease that arises from drug-induced changes in the structure and function of several inter-related brain circuits. This research also has shown that addiction can be treated effectively with evidence-based therapies. As our understanding of addiction grows, so does our responsibility for ensuring that this knowledge reaches patients as quickly as possible in the form of safe and effective treatments. While moving therapies out of the research laboratory and into the hands of treatment providers involves numerous challenges, NIDA understands that many of these challenges can be overcome by forging a closer working alliance between addiction research and treatment. NIDA’s Blending Initiative accomplishes this by providing the infrastructure and the process needed to integrate research and treatment. As NIDA moves forward in this area, it will continue to work closely with its many collaborators and partners to identify treatment interventions that can be implemented in diverse settings at a reasonable cost by a workforce with moderate training and experience.
Timothy P. Condon, PhD has served as the Deputy Director of NIDA since 1992, where he provides leadership in developing, implementing and managing its research programs and strategic priorities. Prior to that, Dr. Condon served in several senior positions, managing research and service programs at the former Alcohol, Drug Abuse, and Mental Health Administration and directing emerging neuroscience technology assessment for the U.S. Congress, Office of Technology Assessment. He has authored numerous scientific and science policy reports and articles and has received multiple awards for his leadership in setting science policy standards.
Denise Pintello, PhD, MSW is the Special Assistant for the Deputy Director of NIDA at the National Institutes of Health (NIH), overseeing the implementation of innovative initiatives and special projects. In her more than 25 years as a social worker, Dr. Pintello has worked extensively in child welfare, mental health and substance abuse and provided clinical, case management and supervisory services to children and adults. She has also conducted applied research and program evaluations within the fields of child welfare, domestic violence, juvenile justice, mental health and substance abuse.
Lucinda L. Miner, PhD has served as the Deputy Director for Science Policy and Communications at NIDA since 1992, where she coordinates NIDA’s research training and science education programs.Dr. Miner has authored numerous scientific articles and book chapters on the genetic underpinnings of addiction, has served on several Federal Task Forces and Committees, received numerous awards and honors for her leadership in setting science policy standards, including sharing an Emmy award for her contributions to the HBO documentary, Addiction in 2008.
Curtis Balmer, PhD is the senior science writer at JBS International, Inc. He has a PhD in neurobiology and has written widely on substance abuse and addiction.
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Gowing, L. R., & Ali, R. L. (2006). The place of detoxification in treatment of opioid dependence. Curr Opin Psychiatry, 19(3), 266–270.
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Petry, N. M., Peirce, J. M., Stitzer, M. L., Blaine, J., Roll, J. M., Cohen, A., et al. (2005). Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study. Arch Gen Psychiatry, 62(10), 1148–1156.
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This article is published in Counselor, The Magazine for Addiction Professionals, February 2010, v.11, n.1, pp.18-23.
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