TREATMENT CHARACTERISTICS & QUALITY: CHALLENGES AND EBTs

DOUGLAS NOVINS, M.D.UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS

NIDA Roundtable Meeting on Substance Use Disorders among American Indian/Alaska Natives in Urban Settings

Topics to Cover Challenges to Service Delivery

(Qualitative) EBT Knowledge (Qualitative) EBT Engagement (Quantitative) EBT Use (Quantitative) Attitudes Towards EBTs & Perceived

Cultural Appropriateness (Qualitative and Quantitative)

Challenges for Service Delivery Clinical challenges

poverty trauma histories

Infrastructure challenges not having enough staff staff feeling burned out

not having enough time or resources Service system challenges Not having enough housing Access to mental health treatment

Challenges for Service Delivery Clinical challenges

poverty trauma histories

Infrastructure challenges not having enough staff staff feeling burned out

not having enough time or resources Service system challenges not having enough housing Access to mental health treatment

“There are so many survival

needs that come first—

housing, a job, food, things like

outpatient treatment are

probably last on the list.”

“’I grew up in an alcoholic home, I was

raised in a foster home, I was in a

boarding school, I may have had sexual

abuse, I may have been physically

abused or emotionally abused . . . .’ That’s

what’s walking in your door. It’s not

simple….”

“…It’s not ‘I’m drinking a six-pack a day and I really get

drunk on the weekends. Help me sober up.’ [W]hat’s

coming to light for our communities is the

trauma that has happened for so many

generations to our communities and still is happening, so how

do we fix that?

“you have to have a certain amount of flexibility and

willingness to wade through the mud and muck of

peoples’ lives everyday because these people come in here when everything is falling apart.” Therefore,

“at the end of your day, you feel like you just don’t have anything left because . . .

it’s so intense.”

“[Clients] know if they go back to their homeland

there’s all the drinking and drug use going on [so they] relocate, [but] sometimes we have people staying three weeks to a month later waiting for housing

because the [lack of] availability and the

funding.”

“It’s all good and well to have evidence-based

treatment, but for who? Who does it work for? . . .

[Y]ou’ve got to realize that it’s different in each

community.”

Knowledge of EBTs Asked respondents in Phase 2 qualitative

interviews to define EBT. We analyzed their responses relative to Drake et. al.’s (2001) definition: “any practice that has been established as effective through scientific research…” Majority of respondents accuratly defined

evidence-based treatments. “effective” (80%) “research” (71%). Synonyms “empirical” (9%), “data” (9%), and “(it)

works” (28%).

“Pretty simply it’s the treatment techniques that have been researched and have proven to be effective in a population that’s been monitored.”

Knowledge of EBTs 19% were unable to define an EBT.

“You know, I've heard it, I've seen it on the covers of the book. But, no, [I don’t know what it means].”

Knowledge of EBTs More detailed aspects of EBT definitions

Manual – 6% Replication – 3% Hierarchy of evidence – 0%

“Then, someone's going to write a curriculum, manualize it, get it all nice and beautiful, and then, they're going to implement it and see if it works. And, if it works, then it'll be an evidence-based practice and maybe it'll be [listed in] NREPP…”

EBT Use

Psychosocial EBTs

not familiarnot

interested in

see pros and cons

planning on using

using but not

permanentpermanent

useused in

past% w

rating ≥ 4

mean Rating0 1 2 3 4 5 6

Psychosocial TreatmentsCognitive Behavioral Therapy 4.2 1.1 8.9 3.7 24.1 56.4 1.6 82.1 3.6Motivational Interviewing 11.1 2.6 10.5 9.0 19.5 45.7 1.6 66.8 3.2Relapse Prevention Therapy 17.0 3.2 6.4 4.8 14.9 52.6 1.1 68.6 3.0Twelve-Step Facilitation 24.1 7.0 10.7 4.3 9.1 41.6 3.2 53.9 2.6Matrix Model 25.8 10.6 19.1 7.4 12.2 18.5 6.4 37.1 2.2Contingency Mgmt 55.2 7.4 13.7 5.8 6.3 9.5 2.1 17.9 1.2Behavioral Couples Therapy 69.2 3.1 16.2 4.2 4.2 2.6 0.5 7.3 0.8Community Reinforcement & Family Training 76.9 5.8 4.2 7.9 2.6 2.1 0.5 5.2 0.6

Multisystemic Therapy 81.4 5.8 7.9 1.1 1.1 1.6 1.1 3.8 0.4

Novins et al. (in preparation) Use of Evidence-Based Treatments in Substance Abuse Treatment Programs Serving American Indian and Alaska Native Communities.

Psychopharmacologic EBTs

Raw Ratings    

Not Familiar

Not intereste

d in

See pros and

cons

Planning on

using

Using but not

permanent

Permanent use

Used in past

Pct With

Ratings ≥ 4

Mean Rating0 1 2 3 4 5 6

Medication TreatmentsMeds for Comorbidity 37.8 4.2 11.1 3.7 7.4 35.3 0.5 43.2 2.1Meds for Relapse Prevention 26.5 14.8 24.9 5.8 9.5 16.4 2.1 28.0 1.9Meds for Withdrawal 32.6 25.3 15.8 2.6 6.8 15.3 1.6 23.7 1.6

Overall EBT Engagement% of treatment

ratings ≥ 4% of participants with at

least one treatment rating ≥ 4Mean Score SD of Scores

Psychological Treatments (with CBT) 1.95 0.69 38.04% 95.8% (184/192)

Psychological Treatments (without CBT) 1.74 0.72 32.49% 54.2% (103/190)

Medication Treatments 1.88 1.29 31.67% 92.2% (177/192)

Factors Associated with Greater EBT Engagement - PsychosocialVariable B SE PDirect, IHS638 compact, state block grant funding, or tribal funds 0.32 0.13 0.01

Percent of clinical staff that are certified addiction counselor (none versus 1-50%)

-0.41 0.19 0.04

Years of education for clinical staff 0.07 0.03 0.04Program requires clinical staff to use EBTs 0.23 0.11 0.05

EBTs are considered in strategic planning 0.32 0.11 0.01

EBPAS Openness Scale 0.22 0.07 0.002

Factors Associated with Greater EBT Engagement - PsychopharmacologicVariable B SE PServes adolescents 0.61 0.30 0.04Medicaid or Fee for Service Funding 0.61 0.24 0.01Percent of clinical staff that are in recovery (none versus 1-50%) -0.77 0.33 0.02

Years of education for clinical staff 0.22 0.08 0.01

EBT Implementation

RPT CBT MI 12SF MM0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Follow manual exactlyUse the parts thought most helpfulRewrote manual to make it more culturally appropriate or better fit with programDon't use manual but use key concepts

Attitudes Towards EBTs Phase 2 results:

Concerns about cultural appropriateness – 42% Western/Biomedical influence – 19% (negative)

External mandates – 26% Tension between individualized care and

manualized treatments – 16% Resource drain – 13%

“Evidence based just means that they have found a certain treatment approach or philosophy that helps with a certain population and it’s not true for all populations.”

Perceptions of Cultural Appropriateness of EBTs: Latent Classes

Class 1 (n=53) Class 2 (n=96) Class 3 (n=42)0%

10%20%30%40%50%60%70%80%90%

100%

NegativeNeutralPositive

CBT [CM, MM, BCT] (4/9)

28% 50% 22%

Perceptions of Cultural Appropriateness of EBTs: Latent Classes

Class 1 Class 2 Class 30%

10%20%30%40%50%60%70%80%90%

NegativeNeutralPositive

MI [RPT, CRFT, MST](4/9)

Perceptions of Cultural Appropriateness of EBTs: Latent Classes

Class 1 Class 2 Class 30%

10%

20%

30%

40%

50%

60%

70%

NegativeNeutralPositive

12-SF (1/9)

Discussion Challenges to Service Delivery

(Qualitative) EBT Knowledge (Qualitative) EBT Engagement EBT Use Attitudes Towards EBTs & Perceived

Cultural Appropriateness (Qualitative and Quantitative)