ATTC’s Pearls of Wisdom: Using the Science to Service Laboratory to bridge the gap between research and practice

 By Rosemarie Martin, PhD and Sara Becker, PhD, New England ATTC

The New England ATTC at the Center for Alcohol and Addiction Studies of Brown University has been continuously funded since the ATTC network’s inception in 1993. The mission of the Center for Alcohol and Addiction Studies is to promote the identification, prevention and effective treatment of addiction and its problems through research, education, training, and advocacy.  Having a home in a world-class addiction research center, the New England ATTC fills a unique niche that sets us apart. Our role as technical assistance purveyors, paired with our home in a center dedicated to advancing science, makes us ideally suited to advance the study of implementation science. We are well poised to close the lengthy gap between the development of research-based addiction health services and their adoption to clinical practice. 

The New England ATTC has leveraged our academic partnerships with community providers to improve the standard in the field for rolling out evidence-based practices (EBPs).  The centerpiece of the New England ATTC’s training efforts for the past two decades has been the Science to Service Laboratory. The SSL is a comprehensive, state-of-the-art multi-component implementation strategy that facilitates technology transfer. 

What is unique about the SSL is the inclusion of three key implementation strategies designed to better support the broad process of technology transfer: didactic workshop, performance feedback, and external facilitation. 

The SSL has strengthened the New England ATTC’s capacity for providing intensive technical assistance through ongoing immersive experiences that help infuse EBPs into real world settings.  As a result, the New England ATTC provides a higher proportion of intensive technical assistance relative to the rest of the network: a network-wide analysis in 2020 suggested that 4% of TTC events were classified as intensive technical assistance during COVID, whereas for the New England ATTC this proportion was 30% over the same time period. Early evaluation of the SSL showed that 96% of agencies that completed all of the SSL components ultimately adopted an EBP.

Using contingency management as test case, our ATTC first applied for funding in 2008 to evaluate the SSL strategy compared to the standard at the time, didactic workshop delivered by a national expert, Nancy Petry. 

We offered the SSL multi-component implementation strategy to seven opioid treatment programs within our region and compared that to 11 opioid treatment programs outside of our region that received a didactic workshop. Opioid treatment program staff in both conditions reported on their delivery of contingency management every two weeks for a year. We found that those organizations trained with the SSL model had higher odds of adoption (odds ratios up to times higher than the didactic workshop), higher speed of adoption, and higher overall frequency of adoption.

Still, we thought there was room for improvement. Could we help accelerate the uptake of contingency management in clinics?  Could we help sustain its use? We asked opioid treatment providers from 11 programs in our region how we could more effectively help them to integrate contingency management into their treatment approach and used their feedback to enhance the SSL. With R01 funding from the National Institute on Drug Abuse, our ATTC is partnering on a large-scale cluster randomized trial with 28 opioid treatment programs throughout the region to test our standard SSL strategy versus an enhanced SSL strategy that layers in provider incentives and external facilitation targeting sustainment. 

This five-year project is wrapping up and we are excited to share the results soon.

In the meantime, we are using the lessons learned to partner with the Rhode Island Department of Health to help them rollout contingency management to opioid treatment programs state-wide. Our SSL model has also informed the multi-component implementation strategy currently being used across California in their rollout of contingency management as a Medicaid-reimbursable service.

The SSL continues to evolve as we integrate new scientific findings in behavior change at both individual and organizational levels.  The science to service influence is bidirectional: we learn from scientific research to improve our technical assistance, and we learn from our work in the field providing technical assistance to improve our science.

In recent years, the most popular EBPs for which the New England ATTC receives intensive technical assistance requests include contingency management, motivational interviewing, and Screening, Brief Intervention, and Referral to Treatment. We look forward to continuing to apply the SSL to help organizations implement EBPs and improve the quality of care offered to persons with or in recovery from substance use disorders.

About the authors:

Rosemarie A. Martin, PhD, is Director of the New England ATTC.  Dr. Martin is an Associate Professor at the Center for Alcohol and Addiction Studies at  the BRown University School of Public Health.  

Sara J. Becker, PhD is Co-Director of New England ATTC.  Dr. Becker is the Inaugural Director of the Center for Dissemination and Implementation Science at the Northwestern Feinberg School of Medicine. 

NIATx in New Places: The International Impact of the NIATx Model: Ukrainian healthcare providers increase access to treatment during war

 By: Lynn Madden, PhD, MPA
       Kristina Spannbauer, Communications Specialist for Great Lakes ATTC, MHTTC, & PTTC

In 2003, the NIATx model was first used by 39 providers, each managing their own pilot project as part of the grant-funded Paths to Recovery and Strengthening Access to Treatment and Recovery programs. Dr. Lynn Madden and her team at the APT Foundation managed one of these pilot projects, and she has been a NIATx coach ever since. In honor of the 20^th anniversary of NIATx, we asked Dr. Madden to share how NIATx has grown over the years and the impact it has had on an international scale.   

Thinking back to 2002 or 2003, when your organization first heard about NIATx, what inspired you to apply to be one of the first grantees?

I was at Acadia Hospital, which is a psychiatric hospital in Bangor, Maine that serves people for both substance use disorders and other mental health issues. We were at the beginning of what was clearly a growing issue with opioids and yet our substance use treatment programs were empty. So, when I saw the call for proposals, I thought, [NIATx] is exactly what we need to try to reduce waiting time, increase admissions, and ultimately increase continuation.

As it turned out, we were awarded the NIATx grant, and Dr. Dave Gustafson became our coach. In our first change project, our team's approach to reducing wait times was pretty straightforward — if someone qualifies for this program, just let them in. At the time, we had ample staff and resources, so we tried it and it really worked. Our waiting time decreased, and we had three times as many patients as we did before using NIATx.

I am personally highly invested in practical solutions, so within 12 months after I was introduced to this approach, I became a coach and consultant. I've been able to contribute to the development of NIATx as it has grown over time.  

It's pretty amazing how NIATx has evolved over the past two decades. Since you first became a NIATx coach and consultant, you've expanded the use of NIATx throughout the US and internationally, as well. What is it that allows this process to be so adaptable and successful in different environments?

One of the key ideas of NIATx is that you select an aim, and the aim is related to improving the customer's experience. It's not implementation for implementation's sake. There is also this amazing parallel process that I think is what fundamentally distinguishes NIATx from other kinds of implementation frameworks. That is the way NIATx allows us to improve service delivery and client outcomes while increasing the strategic advantage of the organization overall.

A NIATx change team is designed to include the voices, thoughts, and experiences of folks working at all levels of an organization as well as the needs of the customer. How has this concept translated when applying the model on a larger scale or in international settings?

We started working in Ukraine in 2014. I was requested to lead a NIDA grant funded NIATx collaborative of Ukrainian chief physicians and stakeholders representing communities across the country with the aim of addressing opioid use disorder. One of the first things we did was a series of nominal group technique exercises, which was something they had never done before. A key feature of the nominal group technique is everyone has a voice. Everyone has an opportunity to speak. The result of our team using the nominal group technique was that we were able to create a series of public health priorities related to the treatment of substance use disorders, and these priorities were shared with the Ministry of Health in Ukraine.

One of the most valuable long-term outcomes of this NIATx collaborative is the network of practice they built with each other and maintain to this day – even throughout the extreme challenges and widespread public health crises caused by the war in Ukraine. This group adopted NIATx tools. They used the findings from nominal group technique to focus their efforts. Thanks to their continued work, today approximately 70% of Ukrainians who use medications to treat opioid use disorders (MOUDs) have access to take-home medications. In 2014, before the initial NIATx change team convened and offered their recommendations to the Ministry of Health, the number of people with take-home MOUDs was zero.

We are still working with them, by the way. Something I would really like to share is that this collaboration of physicians has continued to increase the number of patients receiving treatment throughout the war. They go to work in places that are not very safe. None of them have stopped working unless their entire facility has been bombed, which has happened in a couple of places. In which case, they move to another part of the country, and they keep working. They consider providing their patients with the healthcare they need to be well as their national duty. That is an amazing demonstration of dedication and fortitude.

Do you have any final thoughts or advice you'd like to share?

Participating in that first NIATx grant and developing a working relationship with Dave Gustafson has profoundly impacted my life and career. I think he is a transformational person, and the NIATx model has been transformational to my professional experience and to those who I've coached since I first learned about it.

I also want to mention that I recently co-wrote a grant with some folks in Lima, Peru that is heavily focused on using NIATx in a learning collaborative setting. Lima was awesome, and it's exciting that we keep finding new opportunities to share this approach to process improvement with organizations and communities who are eager to make a difference.

Read more about Dr. Madden's work:

·       Collaborative learning and response to opioid misuse and HIV prevention in Ukraine during war (The Lancet Psychiatry, 2022)

·       Extending a lifeline to people with HIV and opioid use disorder during the war in Ukraine (The Lancet Public Health, 2022)

·       Rapid transitional response to the COVID-19 pandemic by opioid agonist treatment programs in Ukraine (Journal of Substance Abuse Treatment, 2021)

·       The development and initial validation of the Russian version of the BASIS-24 (Addiction Science & Clinical Practice, 2022)

·       Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine (International Journal of Drug Policy, 2017)

Lynn M. Madden, PhD, MPA

Dr. Madden’s work focuses on identifying treatment gaps in substance abuse/mental health treatment and improving both access to services and retention in treatment, with an emphasis on inclusion of marginalized persons and integration with primary care/treatment for infectious diseases such as HIV/AIDS and HCV. She is affiliated with Yale School of Medicine, Internal Medicine - AIDS. Since 2006, she has served as Chief Executive Officer of APT Foundation, a non-profit agency founded in 1970 by members of the Yale School of Medicine Department of Psychiatry.  Under her leadership, APT has grown from serving 1,300 persons to over 8,000 persons every year regardless of ability to pay.  Dr. Madden is also a consultant and NIATx Coach working throughout the United States since 2004, Ukraine since 2014, and Central Asia since 2021, specializing in improving treatment access and program outcomes through the use of implementation science frameworks.

REFERENCES

Altice, F. L., Bromberg, D. J., Klepikov, A., Barzilay, E. J., Islam, Z., Dvoriak, S., ... & Madden, L. M. (2022). Collaborative learning and response to opioid misuse and HIV prevention in Ukraine during war. The Lancet Psychiatry, 9(11), 852-854.

Altice, F. L., Bromberg, D. J., Dvoriak, S., Meteliuk, A., Pykalo, I., Islam, Z., ... & Madden, L. M. (2022). Extending a lifeline to people with HIV and opioid use disorder during the war in Ukraine. The Lancet Public Health, 7(5), e482-e484.

Madden, L., Bojko, M. J., Farnum, S., Mazhnaya, A., Fomenko, T., Marcus, R., ... & Altice, F. L. (2017). Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine. International Journal of Drug Policy, 49, 48-53.

Madden, L. M., Farnum, S. O., Bromberg, D. J., Barry, D. T., Mazhnaya, A., Fomenko, T., ... & Altice, F. L. (2022). The development and initial validation of the Russian version of the BASIS-24. Addiction science & Clinical Practice, 17(1), 65.

Meteliuk, A., de Leon, S. J. G., Madden, L. M., Pykalo, I., Fomenko, T., Filippovych, M., ... & Altice, F. L. (2021). Rapid transitional response to the COVID-19 pandemic by opioid agonist treatment programs in Ukraine. Journal of Substance Abuse Treatment, 121, 108164.

ATTC's Pearls of Wisdom: Saving Lives and Advancing Behavioral Health Equity, Diversity, & Inclusion

 By: Dr. Susie Villalobos, National Hispanic Latino Addiction Technology Transfer Center

SAMHSA Addiction Technology Transfer Centers

In the realm of behavioral health, access to effective treatment and support services is crucial for individuals facing mental health challenges or substance use disorders. The Substance Abuse and Mental Health Services Administration (SAMHSA) has taken significant strides in promoting behavioral health equity, diversity, and inclusion through its Addiction Technology Transfer Centers (ATTC). Let’s explore the vital work of SAMHSA ATTC, highlighting its efforts to save lives and foster a more inclusive and equitable approach to behavioral health.

The ATTC is a national network comprising 10 regional centers, and two national centers focused on specific populations – the American Indian/Alaska Native ATTC, and the National Hispanic and Latino ATTC. Each center is tasked with disseminating evidence-based practices and fostering workforce development in the field of substance use disorder treatment and recovery. 

ATTCs collaborate with various stakeholders, including treatment providers, policymakers, and community organizations, to improve the delivery and accessibility of behavioral health services.  The network also  recognizes that behavioral health disparities disproportionately affect marginalized communities. To address this issue, the centers prioritize initiatives aimed at achieving behavioral health equity. They focus on increasing access to care, reducing stigma, and improving cultural competence among service providers. 

By equipping professionals with the necessary knowledge and skills, the ATTCs contribute to reducing disparities and ensuring that all individuals, regardless of their background, receive equitable care.

Diversity and inclusion are vital components of effective behavioral health systems. The ATTC Network actively promotes these principles by fostering a culturally responsive approach. The centers work to create an environment that respects and embraces diverse perspectives, acknowledging the unique needs and experiences of individuals from various backgrounds. By facilitating cross-cultural understanding, the ATTCs empower providers to deliver person-centered care that accounts for cultural, linguistic, and other relevant factors.

National Hispanic/Latino ATTC

Recognizing that a one-size-fits-all approach may not be effective, the National Hispanic/Latino  ATTC provides tailored technical assistance to organizations and providers working with Hispanic/Latino populations. This assistance includes guidance, resources, and support to help these entities develop and implement culturally competent policies, practices, and programs. By addressing specific needs and challenges, the National Hispanic and Latino ATTC empowers organizations to enhance their services and improve outcomes for the communities they serve.

Our center places a strong emphasis on engaging community stakeholders, recognizing that collaboration and community involvement are essential for achieving behavioral health equity. We work closely with community-based organizations, advocacy groups, and grassroots initiatives to understand the unique needs and challenges faced by Hispanic/Latino communities. By fostering partnerships, our center ensures that our training and technical assistance efforts are informed by lived experiences and community insights.

A significant barrier to accessing behavioral health services for Hispanic/Latino individuals is language. To address this issue, the National Hispanic and Latino ATTC ensures that their training and technical assistance materials are available in multiple languages. We prioritize linguistic competence, providing resources and training in Spanish and other languages commonly spoken within the Hispanic/Latino population. This commitment to language access helps bridge the communication gap and ensures that individuals can access and understand the information and support they need.

Beacon of progress

Promoting behavioral health equity, diversity, and inclusion requires intentional efforts and dedicated initiatives. The National Hispanic and Latino ATTC serves as a beacon of progress in this regard. Through our comprehensive Training and Technical Assistance, we work tirelessly to empower behavioral health professionals, organizations, and community stakeholders to better understand and address the unique challenges faced by Hispanic/Latino communities. By prioritizing cultural competence, linguistic access, and community engagement, we actively contribute to the development of a more equitable and inclusive behavioral health landscape.

These efforts serve as an inspiration for the field, highlighting the transformative potential of training and technical assistance in creating lasting change. The National Hispanic and Latino ATTC has proudly served the SAMHSA network since 2019. During that short time have produced a two-day, in-person national conference with a 98% satisfaction rate from 320 participants, a National Hispanic Latino Executive Leadership Academy with a 95% graduation rate, the Latinos Con Voz podcast series found on Apple and Spotify, and countless toolkits, webinars, short videos and technical assistance activities.

The ATTC Network’s commitment to saving lives and advancing behavioral health equity, diversity, and inclusion is commendable. Through training, technical assistance, and collaborative partnerships, ATTCs empower providers to offer high-quality care that meets the needs of diverse populations. By prioritizing cultural competence and reducing disparities, our network plays a pivotal role in creating a more inclusive and equitable behavioral health system, where every individual can access the support, they need to thrive.

About the author:

Dr. Susie Villalobos is the director of the National Latino Hispanic Addiction and Prevention Technology Transfer Centers. Before joining the National Latino Behavioral Health Association, Dr. Villalobos worked with academic institutions and non-profits as a public advocate and researcher by implementing and managing clinical and socio-behavioral studies/programs. Her expertise in working with local, state and federal agencies stems from her associations with CBOs focused on activities committed to focusing on health disparities among Latino populations living and working on the U.S. – Mexico Border. She is a 2020-2021 graduate from the National Hispanic Latino and National Latino Behavioral Health Leadership Academy. She is particularly passionate about tackling issues faced by Latino populations across, age, race, gender, and biographical location. Her federal grant management experience includes the implementation of the SAMHSA Strategic Prevention Framework to communities focused on substance use prevention efforts in the four states of California, Arizona, New Mexico, and Texas. Dr. Villalobos was trained at the BNI ART Institute at Boston University School of Public Health, to integrate and apply Screening, Brief, Intervention and Referral to Treatment (SBIRT) to Latino individuals presenting substance use risk behaviors in an emergency room setting delivered by promotores. Dr. Villalobos received her doctorate in Educational Administration and Leadership from the Department of Education at the University of Texas at El Paso, and a master’s degree in educational psychology from the Department of Education at the University of Texas at El Paso.