Implementing Evidencebased Practices: What have we Learned

1
Implementing Evidence-based Practices What have
we Learned?

• Richard A. Rawson, Ph.D.
• UCLA Integrated Substance Abuse Programs (ISAP)
• Los Angeles, California
• Principal Investigator, CSAT Pacific Southwest
  Addiction Technology Transfer Center and Los
  Angeles Practice Improvement Collaborative.
• Co-Principal Investigator Pacific Node of the
  NIDA Center for the Clinical Trials Network

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Strategies for Promoting Adoption of
Evidence-Based Practice Pre 2000

• Policy of Benign Neglect (Spiro Agnew, 1968).
• Build it and they will come (Shoeless Joe
  Jackson, Field of Dreams, 1986).
• A chicken in every pot a manual on every shelf
  (Herbert Hoover, 1932 as modified by RR 2002).

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Top ten ways to make sure a treatment approach
does not get adopted.

• 10. Require expensive, specially educated/
  licensed staff to deliver it.
• 9. Make sure it involves using block grant money
  in ways that are of questionable legality.
• 8. Use medications that cost 10 per pill that
  are not covered by insurance or Medicaid.
• Credit and apologies to David Letterman, Kathy
  Carroll and others

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Top ten ways to make sure a treatment approach
does not get adopted (cont)

• 7. Employ treatment manuals that have
• A. 400 pages.
• B. 300 words per page in 8 point font.
• C. No pictures, tables or illustrations.
• D. Language that requires a doctoral level of
  education to understand.
• E. Lots of abstract concepts and theoretical
  principles.
• F. No examples or short hand expressions to help
  aid memory.

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Top ten ways to make sure a treatment approach
does not get adopted (cont)

• 6. Conduct a 3-day intensive training, with 8
  hours per day of didactic lectures, a half hour
  lunch and no breaks. OR
• 6a. Conduct a one-hour overview, give them a
  manual and let send them out as experts.
• 6b.Give them 2 hours and call it a train the
  trainers session.
• 5. Use an approach requiring numerous individual
  sessions in a program where caseloads are 50
  patients or more.
• 4. Create expectations that they will have a 100
  success rate from day 1.

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Top ten ways to make sure a treatment approach
does not get adopted (cont)

• 3. Insist the treatment approach will work for
  every patient regardless of ethnicity, gender,
  age, drug type, etc. when it doesnt work, blame
  the staff.
• 2. Have a trainer who
• A. Uses no A/V support and reads long passages
  from academic textbooks.
• B. Reads his/her power point slides verbatim and
  talks to the screen.
• C. Has never been in a treatment program.
• E. Has the interpersonal charisma of a fence post.

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Number 1 way to to make sure a treatment approach
does not get adopted

• STATISTICS!!

8
Lessons from Pharmacotherapy Development

• Naltrexone for Heroin Addiction
• A medication (naltrexone) that requires an
  extended pre-induction detoxification period, is
  expensive and has major patient compliance
  problems is very minimally used. (Ling, Huber and
  Rawson, 2000)

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Lessons from Pharmacotherapy Development

• LAAM for Heroin Addiction
• A medication (LAAM) that is only moderately
  different from an accepted medication (methadone)
  will not be used if there are substantial
  regulatory obstacles, no clear clinical or
  financial advantages and new procedures and
  expertise are required (Rawson et al, 1998).

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Lessons from Pharmacotherapy Development

• Naltrexone for Alcoholism
• The treatment of alcoholism with naltrexone has
  been found to have occurred in 44 of a sample of
  private treatment centers. Adoption of
  naltrexone was associated with patients referred
  by managed care companies, centers who have
  medically trained administrators, and centers who
  have longer organizational histories. (Roman, et
  al, 2002)

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Lessons from Pharmacotherapy Development

• Naltrexone for Alcoholism
• The use of naltrexone for alcoholism is very
  minimal in California publicly-funded substance
  abuse treatment programs. Use of naltrexone is
  influenced by the cost of the medication, the
  degree of physician involvement in the treatment
  program and the amount of training on naltrexone
  that had been done with the treatment staff.
• (Rawson et al, In Preparation)

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Implementation of motivational interviewing using
a single workshop session

• The training in motivational interviewing
  techniques using a single intensive workshop,
  delivered by experienced trainers did not result
  in the successful acquisition of motivational
  interviewing skills. (Miller and Mount, 2001)

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Implementation of Motivational Interviewing using
Distance Learning Approach

• Extensive program of motivational interviewing
  training conducted over a video-broadcast network
  changes knowledge, but not clinical practice.
• (Shafer, In preparation)

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Role of Clinical Trials in Moving Research to
Practice

• Clinical trial research is an essential activity
  in establishing the efficacy of new treatment
  approaches.
• The demonstration of efficacy is one of the first
  steps in establishing the empirical support for a
  treatment approach.

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Role of Clinical Trials in Moving Research to
Practice

• The co-location of clinical trials research in
  community treatment programs (NIDA CTN) is very
  likely to increase the knowledge and acceptance
  of addiction research by practioners in the
  field.
• The increased contact between researchers and
  clinicians promoted by the CTN trials and related
  activities is likely to increase research on
  clinically relevant topics and promote the
  adoption of research findings in community
  settings

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Use of a Clinical Trial to Promote Practice Change

• Participation in a multi-site clinical trial of
  the Matrix Model did not appear to promote the
  use of this outpatient approach when assessed at
  study end.
• (Hamilton, under review)

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Limitations of Clinical Trials as methods of
Transferring Technology

• Clinical trial research protocol emphasizes data
  collection rigor and rigid protocol compliance.
  Often this is incompatible with flexibility
  needed in clinical practice.
• Participant (subject) inclusion/exclusion
  criteria often excludes real world patients and
  reduces generalizability to standard clinical
  settings.

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Limitations of Clinical Trials as methods of
Transferring Technology

• Frequently, the clinical trial ends without
  teaching clinical staff how to integrate method
  into standard practice.
• At the end of the trial there is often a long
  period needed to complete follow up, analysis and
  write up of results. Frequently the staff
  involved in the trial are gone when results are
  complete and made public.

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Lessons learned from the successful
implementation of methadone

• Problem with public concern about crime and
  health issues.
• Political leaders invested in finding a solution.
• Good data to support approach.
• Champion in position of power (Jaffe).
• Money invested to support implementation.
• Delivery system avoids reforming existing system.
• Local champions created.

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Implementing Evidence-based Practices What does
work?

• Implementation of the Job Seekers Workshop A
  job seekers workshop, an employment preparation
  program was not successfully implemented by
  supplying treatment programs with the program
  manual. There was significant evidence of the
  program when the manual was accompanied by
  on-site training and follow up sessions.
  (Sorensen, et al. 1986)

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Implementing Evidence-based Practices What does
work?

• Training in cognitive-behavioral therapy
• Using a cognitive behavioral therapy training
  program that required over 100 hours of didactic
  training and ongoing clinical supervision, there
  was a substantial adoption of CTB in community
  treatment programs. (Morganstern et al. 2001)

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Implementing Evidence-based Practices What does
work?

• Contingency Management
• In a study to identify strategies to promote the
  use of contingency management by counselors in a
  methadone clinic, it was determined that feedback
  to counselors and reinforcement for use of the
  technique promoted adoption of CM. Feedback
  about the value of the technique produced a major
  increase in the use of the technique.
  (Andrzejewski, et al. 2001

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Implementing Evidence-based Practices What does
work?

• LACES An implementation program of the ASI
• Pressure for accountability
• Involvement of community stakeholders and
  providers in the design and implementation plan.
• Involvement required by administrative agency to
  receive funding.
• Clear goal and regular data feedback to community
  stakeholder group.
• Initial cohort of trainees are voluntary to
  establish procedures and work out challenges.

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Implementing Evidence-based Practices What does
work?

• LACES (cont)
• Employ software that is user friendly.
• Payoff for staff and organization is
  computerized clinical reports that meet
  requirements for accrediting agencies.
• Training, technical assistance, more training and
  more technical assistance, etc.
• Report data regularly to providers.
• Establish practice as normative/necessary to
  define adequate standard of care.
• Patience and perseverance.

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Implementing Evidence-based Practices What does
work?

• Matrix Model Implementation in Thailand
• Serious identified problem (methamphetamine)
• No established, accepted treatments
• Major support from governmental and other opinion
  leaders
• Implementation conducted concurrently with
  meaningful, relevant, targeted evaluation data
  collection system. (Ling, Obert, Rawson et al, In
  prep)

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Implementing Evidence-based Practices What does
work?

• Matrix Model Implementation in Thailand (cont)
• Elements of Training
• Key group of clinical leaders brought to Los
  Angeles for 2 week extensive didactic and
  experiential training experience.
• Matrix manual, translated and culturally adapted
  by Thai clinical leaders.
• Program adaptations suggested to address common
  clinical problems (engagement, retention,
  behavioral compliance).

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Implementing Evidence-based Practices What does
work?

• Matrix Model Implementation in Thailand (cont)
• Elements of Training
• Involvement of clinical leaders in design of
  training
• Multiple follow up and booster sessions with
  visits from US.
• Successful sites given recognition and status as
  training centers
• Data from engagement and retention presented
  publicly programs performing well receive praise

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Elements for Successful Implementation of
Evidence-based Practices

• Focus effort on few selected topics of critical
  community need
• Follow intensive training with ongoing follow up
  sessions and clinical supervision
• Make training/technical assistance readily
  available, provide CEUs and certification for
  training
• Measure implementation of new procedures
• Incentivize application of new procedures
• Create community champions of procedure

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Elements for Successful Implementation of
Evidence-based Practices

• Training
• Engage target audience in choosing topic
• Trainers must be know key elements of treatment,
  treatment environment, patient population and the
  existing practices.
• Engage target audience in selection and methods
  of implementation.
• Engage target audience in deciding parameters of
  success and pay off for success.

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Elements for Successful Implementation of
Evidence-based Practices

• Training
• Training new procedures requires clear
  presentation of method, with manual to guide.
• Manual should be written and illustrated with
  much how to information.
• Training requires experiential component to
  illustrate application (video tapes can be used
  to augment, but not replace this element).

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Elements for Successful Implementation of
Evidence-based Practices

• Training
• Allow trainees to sit in on actual sessions if
  possible.
• Give feedback following initial training with
  some form of knowledge-based proficiency test.
• If possible, give trainees specific goal for
  implementation, with specific parameters for
  completion and measures of fidelity with a
  timetable for supervision/follow-up.

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Elements for Successful Implementation of
Evidence-based Practices

• Training
• Supervision, follow up, problem solve, etc.
  (audiotapes can be used).
• Collect specific data from implementation and
  feed back to staff and organizational leadership.
• Positive reinforcement for technique adoption.

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Principles of Dissemination

• Adaptability
• Trial ability
• Relative Advantage
• Complexity
• Innovation
• (Rogers, 2000) as remembered by RR.