As many health professionals are painfully aware, it takes too long for clinical research results to be implemented in routine patient care—an average of 17 years according to the Institute of Medicine.1 This lag is costly for society and wasteful of knowledge and investments made to improve the health and quality of people's lives—including the millions of lives altered by drug abuse and addiction.

To help translate the results of our rich research portfolio and to systematically move science-based interventions and practices into community settings for use by those who need them, the National Institute on Drug Abuse (NIDA) relies on a dynamic and multifaceted approach, reflected in our Blending Initiative. Blending works by: (1) ensuring bidirectional communication and feedback from a distributed network of researchers, treatment providers, and mainstream public health officials; (2) testing research-based treatments in diverse real-world settings; (3) developing products to facilitate the implementation of treatments that work; and (4) eliciting buy-in from practitioners in the field who will use them. This approach helps to ensure that treatments showing positive results are also practical, are in alignment with community and provider values, and are accepted and used by practitioners in the field––for that is how innovations get adopted in the real world of community-based treatment programs.

To assess the practical effectiveness of proven treatments—crucial in bringing research to practice––NIDA uses as one of its tools the National Drug Abuse Treatment Clinical Trials Network. The CTN involves practitioners from community-based treatment programs in formulating research protocols, trains them to implement and assess the various research-based therapies under study, and elicits feedback on treatment success and feasibility. Training community providers to deliver research-based treatments is a driving force for their use with patients. It also facilitates a continuous improvement loop whereby practitioners identify products needed by the field, then participate in testing and adapting them as necessary.

Developing implementation tools for research-based practices and putting them into the hands of treatment professionals is, of course, a key component of creating the change NIDA is helping to bring about. Blending Teams, composed of NIDA researchers, community treatment practitioners, and representatives from SAMHSA's Addiction Technology Transfer Center (ATTC) program (which NIDA partially supports), create products designed to foster adoption of new research-based treatment strategies. The ATTCs, a network of 14 regional offices and a national office, monitor, translate, and disseminate advances in addiction research, and provide treatment professionals with assistance to enhance needed skills.

Reaching justice populations

Whereas the overriding mission of NIDA's CTN is to improve the quality of drug abuse treatment by moving innovative approaches into the larger community, research supported through our Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) initiative is designed to effect change by bringing new treatment models into the justice system and thereby improve outcomes for offenders with substance use disorders. It seeks to better integrate drug abuse treatment with public health and public safety systems, and represents a collaboration among NIDA, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), Department of Justice agencies, and a host of drug treatment, criminal justice, and health and social service professionals.

A research-based tool recently developed for criminal justice system professionals summarizes the key tenets of what constitutes effective treatment for offenders. Titled Principles of Drug Abuse Treatment for Criminal Justice Populations, the guide, revised this year, highlights some of the proven components for successfully treating prisoners and parolees and thus helping to lower rates of criminal activity and recidivism. It is intended for use not just by the criminal justice community but by treatment professionals working with drug-abusing offenders. The guide describes 13 research-based treatment principles and answers frequently asked questions about drug abuse treatment for justice-involved individuals.

In time, the blending of clinical research and practice will enable the drug treatment field to identify interventions, or key aspects of them, that can be adopted consistently in diverse treatment settings, including criminal justice settings, and help bring about better outcomes for varied patient populations. Indeed, this is already starting to happen.

Findings from CTN studies

The Blending Initiative embraces the notion that hands-on experience with using new protocols and seeing them work influence their adoption by community-based treatment programs and underscore the value of promoting greater interaction among researchers, practitioners, and other stakeholders. To illustrate, the remainder of this article focuses on two protocols: buprenorphine detoxification and motivational incentives, whose adoption by community programs participating in the clinical trials illustrates the value of practitioner involvement in research networks.

Detoxification is the first step in helping opioid-addicted patients recover, which ultimately depends on their continuing in treatment. Medications can be particularly useful for assisting detoxification; buprenorphine, one of our most recently developed medications, shows particular effectiveness in treating opioid addiction. However, positive research outcomes in and of themselves have not counteracted the entrenched biases many treatment programs maintain against the continued use of medications once the patient is abstinent. To introduce this concept to the field, a buprenorphine detoxification protocol was tested in the CTN, with the help of treatment providers who were trained in the protocol and who witnessed firsthand its positive effects. Research results showed that buprenorphine was more effective than standard treatment using clonidine in terms of both treatment retention and drug-free urines.2

Based on these positive results, a training packet was developed to provide physicians and other treatment providers with step-by-step instructions for how to implement the 13-day buprenorphine taper regimen in treatment settings. The training material also reviews CTN research results comparing buprenorphine and clonidine in inpatient and outpatient settings for adult heroin addicts. Other topics include methods of evaluation and induction, the taper schedule, and use of ancillary medications during detoxification. Non-physician treatment professionals must team up with physicians to provide buprenorphine, working with the patient as informed collaborators.

Gregory Brigham, PhD, a member of the Blending Team that developed the buprenorphine detoxification package, is also the chief research officer at the Maryhaven community-based treatment program in Columbus, Ohio. Brigham's center participated in the clinical trial of the buprenorphine taper and later adopted the treatment. In a retrospective review of patients before and after implementation of the buprenorphine taper in the center, about 85% of the buprenorphine group completed treatment, compared with only 55% of the clonidine group. In addition, about 80% of those receiving buprenorphine continued in further treatment, compared to 30% receiving clonidine.3 Brigham called this finding “remarkable” for an inpatient taper.

Based on this successful experience, Maryhaven regularly receives inquiries from other community-based treatment programs considering adoption of the protocol—an example of how early adopters can help to seed the field.

In addition to developing effective pharmacotherapies, researchers also understand the need for interventions to motivate patients to attend treatment and sustain abstinence. In this regard, the research literature has long supported motivational incentives, or contingency management, as a way to help people in drug abuse treatment sustain abstinence. This technique applies the basic principles of behavioral modification in substance abuse treatment settings. Rewards in the form of vouchers exchangeable for goods or services or the granting of privileges are provided for verified abstinence (see related article in September/October 2006 issue). But while research has shown this approach to work, the use of motivational incentives has not been widely embraced by the treatment community. In addition to the perceived financial and administrative burdens associated with obtaining and distributing incentives, some providers simply cannot embrace a philosophy of care that to them seems to reward people for what they should be doing anyway.

To overcome this barrier, a multisite clinical trial was conducted that involved treatment practitioners and 415 stimulant (methamphetamine and/or cocaine) abusers, most from community treatment programs in the western United States.4 In this primary study, approximately half of the participants were randomly assigned to receive, along with 12 weeks of standard care, low-cost rewards or motivational incentives for drug abstinence; the participants drew from a fish bowl to receive their rewards. Findings revealed that those assigned to the incentive condition remained in treatment for a longer period than those assigned to standard care. They also submitted more drug-free urine samples and were more likely to achieve 4, 8, and 12 weeks of continuous abstinence than those participating in standard care alone.

In a later study of motivational incentives among stimulant abusers in six community-based methadone maintenance clinics across the country, participants were twice as likely to submit negative urines as the “for usual” group and 11 times more likely to achieve 12 weeks of continuous abstinence––at an average cost of $120 per patient.5 Thus, the technique is not only effective, but presents a low-cost, viable, and acceptable approach for use by community treatment providers.

In a recent case study examining a large hospital system's successful adaptation of motivational incentive techniques (stemming from CTN exposure), interviews with administrators, staff, and patients revealed a shared sense that the use of contingency management had: (1) increased patient motivation for treatment and recovery; (2) facilitated therapeutic progress and goal attainment; (3) improved the attitude and morale of many staff members and administrators; and (4) developed a more collegial and affirming relationship not only between patients and staff, but also among staff members.6

According to John Hamilton, a member of the Blending Team that created the products based on this protocol and a treatment network CEO, implementation of motivational incentives at the CTN-affiliated center he worked with not only inspired change among patients but also re-energized staff and reduced turnover. He notes: “Our staff really started enjoying coming to work and celebrating catching the patient doing something good instead of something wrong.”

The motivational incentives training package responds to the need to overcome apprehension in the field about using the technique. Known as Promoting Awareness of Motivational Incentives, this package includes a training video, a PowerPoint presentation, a brochure, and a CD of resources.

The culture is changing

The approach of testing innovative treatments directly with diverse community populations, and involving treatment providers in this process so they can “see” them working, is one that responds to the urgent needs of people suffering from addiction. It promises to be a vanguard for how we deliver treatment in this country. A recent report by the National Treatment Center Study (NTCS), a family of projects designed to document and track changes in the service delivery patterns of substance abuse treatment programs throughout the United States, bears this out. The report, which sought to understand the factors that increase receptivity to evidence-based treatment practices, examined how being part of a CTN-affiliated treatment program influenced the subsequent adoption of treatment innovations. Findings indicate that more training in implementing evidence-based practices led to their more routine use within community-based treatment programs. Thus, access to training activities and the opportunity to experience science being put into practice have a positive impact on overcoming barriers and improving counselors' attitudes toward these interventions.7

In the case of the buprenorphine detoxification protocol, a recent study showed that about twice as many CTN-affiliated programs had adopted the protocol compared to non-affiliated programs––20% versus 11%.8 In addition, among CTN-affiliated programs, those directly exposed to buprenorphine through one of the clinical trial protocols were five times more likely to have adopted use of the medication. In the case of voucher-based incentives, roughly one-third of all programs report using this technique, independent of CTN affiliation or participation in the protocol's testing. This shows that diffusion is happening.

Bridging gaps by using what works

The Blending Initiative process is truly a dynamic one that does not wait for research results to be published in peer-reviewed journals, with the hazy hope of eventual translation to practical application. For the first time, science-based products are being made available at nearly the same time that research results are published.

Involving treatment practitioners in dynamic research networks such as the CTN and CJ-DATS is integral to getting treatments more routinely adopted. However, this process is but one aspect of the Blending Initiative. Recurring blending conferences link the scientific community with treatment providers, policy makers, state directors, and grant makers to solidify our blending goals and keep the dialogue fresh and constant. Annual meetings with the National Association of State Alcohol and Drug Abuse Directors help to identify strategies for accelerating the adoption of evidence-based practices into state drug abuse prevention and treatment programs. It is heartening that state agency directors look to NIDA for credible information about selecting, implementing, and sustaining science-based and cost-effective treatment and prevention interventions.

We have the needed structures in place; now we must do the hard work of insisting that each part inform the other. Success requires forging collaborations with an array of public and private partners to help expand our efforts outward and expedite the application of treatments proven effective in preventing and treating drug abuse and addiction. By facilitating a mutually beneficial exchange of knowledge and experience between research and practice domains, NIDA's research infrastructure ultimately will improve the export of treatments from bench to bedside to community. Thus, we are not just bridging the gap between research and practice, but closing it.