1. The University of Georgia Adoption of Medications in Therapeutic Communities: Rates and Organizational Correlates Lori J. Ducharme, Ph.D. Hannah K. Knudsen, Ph.D. Paul M. Roman, Ph.D. University of Georgia With funding support from the National Institute on Drug Abuse (R01DA14976 and R01DA14482)

2. The University of Georgia Studying the adoption of innovations in addiction treatment Substantial recent attention to closing the “research-to-practice gap” in addiction treatment –Pharmacotherapies –Manualized counseling techniques –Wraparound services / case management Public sector generally quicker to adopt wraparound services and some counseling practices Private sector more likely to adopt medications and more resource-intensive psychosocial services

3. The University of Georgia Treatment modality and medication adoption While the public/private distinction explains much of the variance in medication adoption differences, less attention paid to influence of treatment modality/orientation. Public sector includes two major modalities: therapeutic communities and “traditional” community-based treatment programs –TCs: generally long-term residential, highly structured, oriented around “habilitating” clients within strong peer context and increasing responsibilities/rewards –Non-TC programs include shorter-duration treatment, more outpatient, generally 12-step oriented programming, and more emphasis on individual and group counseling Comparing the two modalities permits fuller assessment of influence of program orientation on adoption of medications in context of public sector

4. The University of Georgia Research Questions What are the rates of pharmacotherapy adoption in TCs? What are the organizational correlates of adoption? –How do TCs differ from other public-sector modalities on the predictors of medication adoption? What is the role of program “philosophy” in the adoption of medications? What are the implications for providers?

5. The University of Georgia Study Design Data from two independent samples of treatment facilities in the US: –N=379 therapeutic communities –N=362 public-sector, community based AOD treatment programs Face-to-face interviews with program administrators in 2003-’04. Interviews covered organization and management, staff, caseload, and adoption of various pharmacotherapies and counseling techniques

6. The University of Georgia Sample Characteristics Therapeutic Communities (N=379) Non-TC Programs (N=362) % public revenues*54.485.5 Accredited31.427.4 Surveys buyers/suppliers74.777.1 Employees (FTEs)*24.730.8 Total admissions, last year*357.1849.8 Integrated care for Dual Dx50.750.4 Employs/contracts physician(s)59.163.9 % Master’s level counselors*28.936.2 % primary opiate clients*18.214.4 IP/Residential only*53.622.1 *p<.05

7. The University of Georgia Rates of medication use, by sample (as of 2004) Therapeutic Communities Non-TC Programs Antabuse*7.4%15.2% Naltrexone*5.5%9.2% Methadone7.1%8.9% Buprenorphine3.2%2.8% SSRIs31.9%35.0% Any of these40.1%44.4% *p<.05

8. The University of Georgia Predictors of medication adoption: Logistic regression results (pooled data) Odds Ratio TCsn.s. % public revenuesn.s. Accredited1.86 Surveys buyers/suppliersn.s. FTEs (log)1.24 Integrated care2.89 Physician available3.28 % Master’s counselors3.67 % opiate clientsn.s. IP/Residential onlyn.s.

9. The University of Georgia Administrator interview data: Reasons for not adopting meds

10. The University of Georgia Measuring Program Philosophy TCs: measured adherence to two “traditional” TC concepts: –TC perspective: 6 items on program attitude toward addiction, addicts, recovery process, and “right living” –Community as method: 10 items on commitment to mutual peer support, community belonging, use of privileges/sanctions, and surveillance of clients –Items adapted from DeLeon’s Essential Elements Questionnaire Non-TC Programs: measured commitment to two alternate philosophical orientations –Program follows a 12-step model (yes/no) –Program endorses medical/psychiatric model of addiction (0-to-5 scale) Incorporate these philosophy measures into multivariate models of adoption of meds

11. The University of Georgia Philosophy and Medication Adoption Public Sector Treatment ProgramsTherapeutic Community Programs % public revenuesn.s.% public revenuesn.s. Accreditedn.s.AccreditedOR=2.35 Surveysn.s.Surveysn.s. FTEsn.s.FTEsn.s. Integrated CareOR=3.27Integrated careOR=2.59 PhysiciansOR=2.80PhysiciansOR=3.86 Masters counselorsOR=4.11Masters counselorsn.s. % opiate clientsn.s.% opiate clientsn.s. IP onlyn.s.Residential onlyn.s. Medical modelOR=1.26TC perspectiven.s. 12 step modelOR=0.51Community as methodn.s.

12. The University of Georgia Summary of Findings Substantial progress has been, and continues to be, made in the development of pharmacotherapies for alcohol and drug dependence Rates of adoption among public sector programs are low, and tend to be even lower in TCs. –But SSRIs have made measurable inroads Structural barriers similarly impact TCs and other modalities in the public sector: –Programs with more staff resources/credentials are better positioned to adopt medications (physicians, master’s level counselors, more FTEs) –Programs offering integrated SA/MH care are more likely to have adopted SSRIs –TCs no different when other organizational factors are controlled

13. The University of Georgia Implications for Research & Practice Both modalities cite “philosophy” as barrier to adoption of meds –Medical model programs more likely to have adopted –Independent measures of “TCness” not associated with adoption –But broader culture of TCs antithetical to medication use In non-TC programs, more emphasis on integrated care, staff education, and linkages with physicians may increase receptivity toward medications For TCs, more research is needed on the clients to whom meds are currently prescribed, and the context in which Rx decisions occur –Is low adoption by TCs necessarily bad? –Does adoption of psychosocial counseling approaches and wraparound services follow similar patterns?