The use of off-label medications in substance abuse treatment programs.

Background: Substance use disorder (SUD) treatment centers serve a population of clients who have diverse needs, and may desire or require access to varied treatments while seeking care for their SUDs. While pharmacotherapies have increased in popularity for the treatment of SUDs, adoption rates do remain quite low. But a wider array of pharmacotherapies has become available in recent years which may shift the trend. This article helps shed light on how variations in SUD treatment centers develop and persist with regard to the adoption and delivery of off-label medications. Methods: We use a nationally representative and longitudinal sample of SUD treatment centers in the US (N = 196). We use a logistic regression to analyze the relationship between organizational characteristics and offering any medications, off-label. We also use a negative binomial regression to analyze the relationship between organizational characteristics and the number of medications that were used off-label. Results: Our findings reveal that older centers, accredited centers, and centers that offer mental health screenings are all positively associated with the provision of off-label medication in SUD treatment. We also find a positive relationship between private funding and offering a greater number of off-label medications. Conclusions: Our results suggest that SUD clients who seek treatment from centers that offer medications off-label, may have access to a greater number of medication-assisted treatment options.

Service delivery and pharmacotherapy for alcohol use disorder in the era of health reform: Data from a national sample of treatment organizations.

BACKGROUND: Although there is a growing literature examining organizational characteristics and medication adoption, little is known about service delivery differences between specialty treatment organizations that have and have not adopted pharmacotherapy for alcohol use disorder (AUD). This study compares adopters and nonadopters across a range of treatment services, including levels of care, availability of tailored services for specific populations, treatment philosophy and counseling orientations, and adoption of comprehensive wraparound services. METHODS: In-person interviews were conducted with program leaders from a national sample of 372 organizations that deliver AUD treatment services in the United States. RESULTS: About 23.6% of organizations had adopted at least 1 AUD medication. Organizations offering pharmacotherapy were similar to nonadopters across many measures of levels of care, tailored services, treatment philosophy, and social services. The primary area of difference between the 2 groups was for services related to health problems other than AUD. Pharmacotherapy adopters were more likely to offer primary medical care, medications for smoking cessation, and services to address co-occurring psychiatric conditions. CONCLUSIONS: Service delivery differences were modest between adopters and nonadopters of AUD pharmacotherapy, with the exception of health-related services. However, the greater adoption of health-related services by organizations offering AUD pharmacotherapy represents greater medicalization of treatment, which may mean these programs are more strongly positioned to respond to opportunities for integration under health reform.

Counselor training and attitudes toward pharmacotherapies for opioid use disorder.

BACKGROUND: Methadone and buprenorphine have been demonstrated to be effective in the treatment of opioid use disorder (OUD), especially when combined with psychosocial treatment. Despite buprenorphine's association with fewer withdrawal symptoms and lessened risk of abuse, compared with methadone, its adoption remains limited. Given the vital role that counselors may play in its successful implementation, their knowledge and perceptions of opioid agonist therapy may be facilitators or barriers to its acceptance. METHODS: Informed by diffusion theory, the current study examined perceptions of buprenorphine's and methadone's acceptability among 725 counselors employed in a nationally representative sample of substance use disorder treatment centers. First, we provided descriptive statistics about medication diffusion, extent of training received about the medications, and perceptions of acceptability of each medication. Then, we compared acceptability of opioid agonists with other treatment approaches for OUD. Finally, we conducted 2 ordinary least squares regressions to examine counselor acceptability of buprenorphine and of methadone. RESULTS: Descriptive statistics suggested that diffusion of information about buprenorphine and methadone was not complete, and training was not extensive for either medication. Counselors reported greater acceptability and training of buprenorphine compared with methadone. Methadone was rated as the least acceptable among all other treatment approaches. Multivariate analyses indicated regional differences, and that medication-specific training, adaptability, and educational attainment were positively related with perceptions of acceptability of either medication, even after controlling for organizational characteristics. Adherence to a 12-step orientation was negatively associated with acceptability. CONCLUSIONS: Dissemination of information about opioid agonist therapy is occurring. Nevertheless, the fact that 20% of counselors admitted not knowing enough about either buprenorphine's or methadone's effectiveness is surprising in light of the extensive literature documenting their effectiveness. Future research should focus upon different types of training that can inform physicians, counselors, and patients about the use of opioid agonist therapy.

Rural substance use treatment centers in the United States: an assessment of treatment quality by location.

BACKGROUND: While previous research has added to the understanding of rural residents' unique health challenges, much remains to be learned about the provision of substance use disorder (SUD) treatment in rural areas. A key question is difference in structural resources and quality of care between rural and urban treatment centers. OBJECTIVE: To examine differences in treatment quality in rural and urban centers and to determine if differences in treatment quality are contextualized by centers' structural resources. METHODS: Utilizing combined data from two representative samples of SUD treatment centers (n = 591), we used a series of multivariate regressions to analyze the association between center rurality and various indicators of structural characteristics and treatment quality. Interaction effects were further examined between structural characteristics and treatment quality indicators. RESULTS: We found that structural and quality differences between rural and urban treatment centers were present. Rural centers had reduced access to highly educated counselors, were more likely to be non-profit and dependent on public funding, offered fewer wraparound services, and had less diverse specialized treatment options. Our results also indicated that rural centers were less likely to prescribe buprenorphine as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Rural center access to a physician contextualized the association between center rurality and the more limited provision of wraparound services. CONCLUSION: Our findings suggest that treatment quality differs between urban and rural centers in complex ways that are subject to resource availability.

Organizational Predictors and Use of Evidence-Based Practices in Adolescent Substance Abuse Treatment.

BACKGROUND: Adolescent substance abuse remains a significant problem in the United States, yet treatment centers do not always admit adolescent clients. In this paper, we first determine the extent to which treatment is available for adolescents in general and whether or not adolescent-specific (segregated) tracks are offered. Second, we examine the organizational characteristics associated with adolescent treatment. Third, we illuminate how the adolescent caseload in a treatment center is related to offering evidence-based practices (EBPs). METHODS: Drawing upon a nationally representative sample of US treatment programs, we use logistic regression to assess how organizational characteristics are associated with the provision of adolescent treatment. Using ordinal logistic regression, we analyze how the treatment center's adolescent caseload and organizational characteristics affect the extent to which a treatment center offers medication-assisted treatment (MAT) and psychosocial treatment. RESULTS: Half (49.5%) of treatment programs admitted adolescents, and 41.8% offered an adolescent-specific track. Findings from the logistic regression suggested several organizational characteristics that were significantly associated with treating adolescents and/or having an adolescent-only track. Our findings from the ordinal models indicated a negative relationship between the percent of adolescents in a treatment center and the extent of MAT, and a positive relationship between the percent of adolescent clients and the extent of psychosocial treatment offered. CONCLUSIONS: This paper highlights organizational barriers to treatment entry for adolescents, who remain a small proportion of clients in treatment centers. When treatment centers serve adolescents, however, those adolescents are likely to receive care in adolescent-only tracks and/or services and in programs that offer several psychosocial EBPs. Finally, adolescents are less likely to receive treatment in centers that offer a variety of MAT.

Adopting evidence-based medically assisted treatments in substance abuse treatment organizations: roles of leadership socialization and funding streams.

This paper examines the organizational adoption of medically assisted treatments (MAT) for substance use disorders (SUDs) in a representative sample of 555 US for-profit and not-for-profit treatment centers. The study examines organizational adoption of these treatments in an institutionally contested environment that traditionally has valued behavioral treatment, using sociological and resource dependence frameworks. The findings indicate that socialization of leadership, measured by formal clinical education, is related to the adoption of MAT. Funding patterns also affect innovation adoption, with greater adoption associated with higher proportions of earned income from third party fees for services, and less adoption associated with funding from criminal justice sources. These findings may generalize to other social mission-oriented organizations where innovation adoption may be linked to private and public benefit values inherent in the type of socialization of leadership and different patterns of funding support.

Social workers' knowledge and perceptions of effectiveness and acceptability of medication assisted treatment of substance use disorders.

Data from a national study of 345 privately funded, community-based substance use disorder (SUD) treatment centers were used to investigate social workers' knowledge, perceptions of effectiveness, and perceptions of the acceptability of medication assisted treatments (MATs) for SUDs. Results reveal the importance of exposure to MATs for social workers to develop a knowledge base regarding the effectiveness of various pharmacological agents. Results also underline the importance of social workers' perceptions of effectiveness in forming opinions regarding the acceptability of the use of MATs in SUD treatment. Lastly, a 12-Step orientation toward treatment has a negative influence on social workers' opinions regarding the acceptability of MATs.

Assessment and treatment of co-occurring eating disorders in privately funded addiction treatment programs.

Privately funded addiction treatment programs were surveyed to increase understanding of assessment and current treatment options for patients with co-occurring substance use and eating disorders. Data were collected from face-to-face interviews with program administrators of a nationally representative sample of 345 private addiction treatment programs. Although the majority of programs reported screening for eating disorders, programs varied in screening instruments used. Sixty-seven percent reported admitting cases of low severity. Twenty-one percent of programs attempt to treat eating disorders. These results highlight the need for education of addiction treatment professionals in assessment, referral, and treatment of eating disorders.

Substance abuse treatment for older adults in private centers.

By 2020, an estimated 4.4 million older adults will require substance abuse treatment compared to 1.7 million in 2000-01. This study examined the availability of special services for older adults, adoption of recommended treatment approaches, and organizational characteristics of centers that offer special services. Data were collected via face-to-face interviews with administrators and/or clinical directors from a nationally representative sample of 346 private treatment centers participating in the 2006-07 National Treatment Center Study. Results indicated that only 18% provided special services for older adults; age-specific recommendations were generally adopted; more older adult-specialty centers offered prescription drug addiction treatment, primary medical care, and housing assistance. The proportion of patients with Medicare payment predicted availability of special services. As more older adults will seek help with a myriad of substance use disorders (SUDs) over the next decade, treatment centers need to get ready for a plethora of challenges as well as unique opportunities for growth.

Differences in Substance Abuse Counselors' Knowledge of Tobacco Cessation Medication Effectiveness: 2002-2008.

Counselors play a supportive role in patients' substance abuse treatment, including tobacco cessation. Thus, counselors should be knowledgeable about tobacco cessation medications (TCMs). This study examined differences in counselors' knowledge of and familiarity with (i.e., diffusion) bupropion and nicotine replacement therapy (NRT) between 2002 and 2008 and identified predictors of diffusion. Repeated cross-sectional questionnaire data were obtained in 2002/04 from 992 counselors and in 2007/08 from 1,226 counselors working in private treatment programs. Results indicated that more counselors in 2007/08 did not know about bupropion to rate its effectiveness than in 2002/04; no differences were found for NRT. Among both samples of counselors who were familiar with TCMs, effectiveness was rated higher in 2007/08 than in 2002/04. Findings suggest that educated and trained counselors are important in diffusing TCMs. Knowledgeable counselors may be able to educate patients interested in tobacco cessation about available treatments and encourage compliance with TCMs.

Counselor attitudes toward the use of motivational incentives in addiction treatment.

Counselor attitudes toward evidence-based practices, such as motivational incentives/contingency management (MI/CM), are important in bridging the gap between research and practice. Mailed surveys from 1,959 substance abuse treatment counselors showed ambivalence toward MI/CM and strong disagreement with using monetary rewards for achievement of treatment goals. Attitudes were associated with counselors' educational attainment, a 12-step treatment ideology, affiliation with NIDA's Clinical Trials Network, and working in opioid treatment programs. Exposure to MI/CM via training was more strongly associated with attitudes when counselors worked in programs that had adopted MI/CM. While there is substantial resistance to MI/CM, dissemination and training about the essential elements of MI/CM may enhance counselors' receptivity toward this intervention.

Diffusion of contingency management and attitudes regarding its effectiveness and acceptability.

Substance abuse counselors are critical as the key arbiters of clients' acceptance and use of innovative treatment techniques, with their potential support embedded in their knowledge of and attitudes towards particular innovations. In this analysis the authors examine the role of substance abuse counselors in the adoption of a psychosocial treatment innovation, contingency management (CM). Using data collected from 1140 counselors employed in a national sample of 318 public treatment centers, the authors examine theoretical predictors of counselors' knowledge of CM, and their attitudes regarding CM's effectiveness and acceptability. Findings suggest that lack of exposure to CM through program use and innovation-specific training is the most salient barrier to CM adoption and diffusion. The study also highlights the importance of social networks in the diffusion and acceptance of treatment innovations.

Turnover intention and emotional exhaustion "at the top": adapting the job demands-resources model to leaders of addiction treatment organizations.

Compared with the large literature on subordinate employees, there are few studies of emotional exhaustion and turnover intention for organizational leaders. There is little research that has extended the job demands-resources (JD-R) model of emotional exhaustion to leaders. In this study, the authors adapted the JD-R framework to analyze data collected from a sample of 410 leaders of addiction treatment organizations. The authors considered whether two job demands (performance demands and centralization) and two job resources (innovation in decision making and long-range strategic planning) were associated with emotional exhaustion and turnover intention. The authors also examined whether emotional exhaustion fully or partially mediated the associations between the job-related measures and turnover intention. The results supported the partially mediated model. Both job demands were positively associated with emotional exhaustion, and the association for long-range strategic planning was negative. Emotional exhaustion was positively associated with turnover intention. Centralization and innovation in decision making were also directly associated with turnover intention. Future research should continue to examine this theoretical framework among leaders of other types of organizations using more refined measures of demands and resources.

Modified therapeutic communities and adherence to traditional elements.

Traditional therapeutic communities (TCs) are characterized by confrontational group therapy, treatment phases, a tenure-based resident hierarchy, and long-term residential care. Many TCs have modified the structure and intensity of the traditional model, tailored services for specific client populations, and hired more professionally trained staff. This study examines the extent to which modified TCs are able to retain the underlying core technology of the TC. Using data from a nationally representative sample of 380 self-identified TCs, six traditional TC elements are identified. Results from a structural equation model indicate that offering services for specific populations and professionalization of staff has limited impact on the six TC elements. Modifications to structure and intensity of TC programming evidenced the strongest effect. Specifically, outpatient-only TCs showed significantly lower adherence to five of the six elements. Short-term residential programs showed a similar negative trend. Findings suggest selected modifications are possible without significantly impacting the TC model's core technology.

Health Services Research for Drug and Alcohol Treatment and Prevention.

Health services research is a multidisciplinary field that examines ways to organize, manage, finance, and deliver high-quality care. This specialty within substance abuse research developed from policy analyses and needs assessments that shaped federal policy and promoted system development in the 1970s. After the authorization of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA), patient information systems supported studies of treatment processes and outcomes. Health services research grew substantially in the 1990s when NIAAA and NIDA moved into the National Institutes of Health and legislation allocated 15% of their research portfolio to services research. The next decade will emphasize research on quality of care, adoption and use of evidence-based practices (including medication), financing reforms and integration of substance abuse treatment with primary care and mental health services.

A categorical typology of naltrexone-adopting private substance abuse treatment centers.

This study used a diffusion of innovations theoretical framework [Rogers, E. M. 2003. Diffusion of innovations. 5th edition. New York: The Free Press] to identify organizational-level predictors of a categorical typology of substance abuse treatment centers based on naltrexone adoption. Data from the National Treatment Center Study (N = 158) were used to examine the impact of socioeconomic status, organizational personality, and communication behavior on adopter categorization (i.e., innovators, early adopters, early majority, late majority, or laggards). Results from the ordered logistic regression model indicate that organizations that did not have onsite 12-step meetings and were familiar with treatment innovations were more likely to be in a more innovative category. Organizations that learned about innovations from professional development seminars and informal conversations with external treatment providers were more likely to be in a less innovative category. Identifying and targeting the early and late majority categories of adopting organizations for better training and community linkages could help reduce the research-to-practice gap.

The adoption of medications in substance abuse treatment: associations with organizational characteristics and technology clusters.

Despite growing interest in closing the "research to practice gap", there are few data on the availability of medications in American substance abuse treatment settings. Recent research suggests that organizational characteristics may be associated with medication availability. It is unclear if the availability of medications can be conceptualized in terms of "technology clusters", where the availability of a medication is positively associated with the likelihood that other medications are also offered. Using data from 403 privately funded and 363 publicly funded specialty substance abuse treatment centers in the US, this research models the availability of agonist medications, naltrexone, disulfiram, and SSRIs. Bivariate logistic regression models indicated considerable variation in adoption across publicly funded non-profit, government-owned, privately funded non-profit, and for-profit treatment centers. Some of these differences were attenuated by organizational characteristics, such as accreditation, the presence of staff physicians, and the availability of detoxification services. There was some evidence that naltrexone, disulfiram, and SSRIs represent a group of less intensely regulated medications that is distinct from more intensely regulated medications. These types of medications were associated with somewhat different correlates. Future research should continue to investigate the similarities and differences in the predictors of medication availability across national contexts.

Job stress and poor sleep quality: data from an American sample of full-time workers.

Given the associations between poor quality sleep and health, it is important to consider whether job stressors are related to sleep-related outcomes. Studies from Europe and Japan suggest that these stressors negatively impact sleep, but there are few studies of job stressors and sleep quality that draw upon large representative samples of workers in the USA. Using data collected via telephone interviews from a nationally representative random sample of 1715 American full-time employees, this research considers three dependent variables of past-month poor sleep quality: number of days the respondent had difficulty initiating sleep, number of days of difficulty maintaining sleep, and number of days of non-restorative sleep. Negative binomial regression was used to estimate a count data model of the associations between the frequency of these three types of poor sleep quality and the job stressors of work overload, role conflict, autonomy, and repetitive tasks, while controlling for socio-demographic characteristics. The average American worker reported 5.3 days of difficulty falling asleep, 6.6 days of trouble staying asleep, and 5.0 days of trouble waking up for work in the past month. Across the three types of poor sleep quality, work overload was positively associated with the frequency of poor sleep quality. Role conflict was positively associated with difficulty initiating sleep and non-restorative sleep. Repetitive tasks were associated with more days of difficulty initiating sleep and maintaining sleep. Job autonomy was negatively associated with non-restorative sleep. Given that sleep quality is associated with other health outcomes, future research should continue to explore the associations between job-related stressors, sleep quality, and workers' health status.

Research participation and turnover intention: An exploratory analysis of substance abuse counselors.

Clinical research is increasingly being conducted in community-based addiction treatment settings. Although the primary focus of such research is on the development of effective clinical interventions, less attention has been paid to the potential impact of these projects on counseling staff who are involved in their implementation. Such involvement may be perceived as stressful or rewarding, and these perceptions may be associated with counselors' turnover intention. Using data from 207 counselors involved in research projects conducted within the National Institute on Drug Abuse's Clinical Trials Network, this study examines the associations between counselors' reactions to research experiences and turnover intention. When counselors perceived that research projects resulted in organizational benefits, turnover intention was significantly lower. However, there was a positive association between perceptions of research-related stressors and turnover intention. These findings suggest that the impact of clinical trials on treatment organizations and staff members warrants continued study.

Innovation adoption in substance abuse treatment: exposure, trialability, and the Clinical Trials Network.

Researchers and policymakers are increasingly focusing on factors that facilitate or impede the diffusion of evidence-based treatment techniques into routine clinical practice. One potentially fruitful avenue of research is the influence of involvement in research networks as a predictor of organizational innovation. The Clinical Trials Network (CTN) is examining a number of behavioral and pharmacological treatment techniques in controlled multisite studies. Using data from participating CTN treatment programs and large samples of programs outside the CTN, these analyses examine the influence of exposure to clinical trials on the subsequent adoption of buprenorphine and voucher-based motivational incentives. The analyses show that, controlling for a variety of organizational characteristics, direct exposure to buprenorphine clinical trials in the CTN significantly increased the odds of subsequent adoption. By contrast, the adoption of motivational incentives was entirely explained by organizational characteristics. The findings suggest that adoption of treatment innovations is a function of exposure, organizational resources, nature of innovations, and stage of the diffusion process.