A review of implementation research funded by the National Institute on Drug Abuse, 2007-2023: Progress and opportunities.

BACKGROUND: The ongoing and evolving overdose epidemic highlights the need to translate research results into routine clinical practice to address urgent service delivery needs. Implementation science is a relatively new discipline intended to develop systematic, replicable, scalable strategies to accelerate this translation. This article presents a comprehensive review of implementation research funded by the National Institute on Drug Abuse (NIDA). METHODS: The study identified all NIDA-funded research grants awarded in fiscal years 2007 through 2023 in treatment services or prevention research (n = 1111) and screened them to find those with a pre-specified implementation science component (n = 248). Using the text of the grant application, two reviewers independently coded the key characteristics of each study. RESULTS: The characteristics of these grants, and trends over time, are described, and priority gap areas are identified. NIDA's implementation research grants have demonstrated increasing rigor in design and measurement. CONCLUSIONS: Growth in the portfolio has been driven in part by NIDA's investments in research-practice partnerships in the criminal-legal system, and by recent efforts to address the overdose epidemic.

Knowledge, Attitudes, and Beliefs About Opioid Use Disorder Treatment in Primary Care.

This survey study assesses the US public's perception and awareness regarding medication for opioid use disorder and its availability in primary care settings.

Collaboration and growth in a large research cooperative: A network analytic approach.

Research networks encourage team science and facilitate collaboration within and across research teams. While many analyses have examined the output of these collaborative networks (e.g., authorship networks, publications, grant applications), less attention has been paid to the formative phases of these initiatives. This article presents analyses of a whole-network survey of investigators participating in a new research initiative, and examines the development of collaborative ties over the network's first year. In particular, we examine the influence of research center affiliation, seniority, and prior network experience on the number and structure of collaborative ties, including participants' bridging and broker roles. Such analyses can inform the overall management of the project in purposefully promoting new collaboration opportunities, and may ultimately predict the number of collaborative products generated by the network members.

Engaging the justice system to address the opioid crisis: The Justice Community Opioid Innovation Network (JCOIN).

Many individuals with opioid use disorder come into contact with the justice system each year, making the nexus between the criminal justice system and the health care system a critical juncture for responding to the opioid crisis and simultaneously promoting public health and public safety. Collaborations across these sectors are essential to providing effective screening, treatment, and discharge planning; connecting individuals to services following release; promoting long-term recovery while reducing recidivism; and ultimately bringing the opioid crisis under control. In 2019, with the support of the NIH Helping to End Addiction Long-term (HEAL) Initiative, the National Institute on Drug Abuse launched the Justice Community Opioid Innovation Network (JCOIN). JCOIN is a >$150M multisite cooperative designed to facilitate transdisciplinary collaborations that can create actionable, translatable insights for the justice system and community-based organizations to address the opioid epidemic in justice-involved populations. JCOIN brings together 11 Research Hubs, a coordination and translation center (CTC), and a methodology and advanced analytics resource center (MAARC), with the goal of generating evidence that is greater than the sum of the parts. Collectively, the network will field at least 12 large-scale multisite clinical trials, which are described in this special issue. This article provides a brief overview of the scientific underpinnings for these trials; describes the broad themes connecting them; and discusses the intersections of the JCOIN initiative with the COVID-19 pandemic.

A model for rigorously applying the Exploration, Preparation, Implementation, Sustainment (EPIS) framework in the design and measurement of a large scale collaborative multi-site study.

BACKGROUND: This paper describes the means by which a United States National Institute on Drug Abuse (NIDA)-funded cooperative, Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), utilized an established implementation science framework in conducting a multi-site, multi-research center implementation intervention initiative. The initiative aimed to bolster the ability of juvenile justice agencies to address unmet client needs related to substance use while enhancing inter-organizational relationships between juvenile justice and local behavioral health partners. METHODS: The EPIS (Exploration, Preparation, Implementation, Sustainment) framework was selected and utilized as the guiding model from inception through project completion; including the mapping of implementation strategies to EPIS stages, articulation of research questions, and selection, content, and timing of measurement protocols. Among other key developments, the project led to a reconceptualization of its governing implementation science framework into cyclical form as the EPIS Wheel. The EPIS Wheel is more consistent with rapid-cycle testing principles and permits researchers to track both progressive and recursive movement through EPIS. Moreover, because this randomized controlled trial was predicated on a bundled strategy method, JJ-TRIALS was designed to rigorously test progress through the EPIS stages as promoted by facilitation of data-driven decision making principles. The project extended EPIS by (1) elucidating the role and nature of recursive activity in promoting change (yielding the circular EPIS Wheel), (2) by expanding the applicability of the EPIS framework beyond a single evidence-based practice (EBP) to address varying process improvement efforts (representing varying EBPs), and (3) by disentangling outcome measures of progression through EPIS stages from the a priori established study timeline. DISCUSSION: The utilization of EPIS in JJ-TRIALS provides a model for practical and applied use of implementation frameworks in real-world settings that span outer service system and inner organizational contexts in improving care for vulnerable populations. TRIAL REGISTRATION: NCT02672150 . Retrospectively registered on 22 January 2016.

An Overview of Research and Evaluation Designs for Dissemination and Implementation.

The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. This article is one product of a design workgroup that was formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. This article emphasizes randomized and nonrandomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.

Effects of an Organizational Linkage Intervention on Inter-Organizational Service Coordination Between Probation/Parole Agencies and Community Treatment Providers.

Weak coordination between community correctional agencies and community-based treatment providers is a major barrier to diffusion of medication-assisted treatment (MAT)--the inclusion of medications (e.g., methadone and buprenorphine) in combination with traditional counseling and behavioral therapies to treat substance use disorders. In a multisite cluster randomized trial, experimental sites (j = 10) received a 3-h MAT training plus a 12-month linkage intervention; control sites (j = 10) received the 3-h training alone. Hierarchical linear models showed that the intervention resulted in significant improvements in perceptions of interagency coordination among treatment providers, but not probation/parole agents. Implications for policy and practice are discussed.

Implementing Effective Substance Abuse Treatments in General Medical Settings: Mapping the Research Terrain.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and Veterans Health Administration (VHA) share an interest in promoting high quality, rigorous health services research to improve the availability and utilization of evidence-based treatment for substance use disorders (SUD). Recent and continuing changes in the healthcare policy and funding environments prioritize the integration of evidence-based substance abuse treatments into primary care and general medical settings. This area is a prime candidate for implementation research. Recent and ongoing implementation projects funded by these agencies are reviewed. Research in five areas is highlighted: screening and brief intervention for risky drinking; screening and brief intervention for tobacco use; uptake of FDA-approved addiction pharmacotherapies; safe opioid prescribing; and disease management. Gaps in the portfolios, and priorities for future research, are described.

Effect of an organizational linkage intervention on staff perceptions of medication-assisted treatment and referral intentions in community corrections.

INTRODUCTION: Medication-assisted treatment (MAT) is effective for alcohol and opioid use disorders but it is stigmatized and underutilized in criminal justice settings. METHODS: This study cluster-randomized 20 community corrections sites to determine whether an experimental implementation strategy of training and an organizational linkage intervention improved staff perceptions of MAT and referral intentions more than training alone. The 3-hour training was designed to address deficits in knowledge, perceptions and referral information, and the organizational linkage intervention brought together community corrections and addiction treatment agencies in an interagency strategic planning and implementation process over 12 months. RESULTS: Although training alone was associated with increases in familiarity with pharmacotherapy and knowledge of where to refer clients, the experimental intervention produced significantly greater improvements in functional attitudes (e.g. that MAT is helpful to clients) and referral intentions. Corrections staff demonstrated greater improvements in functional perceptions and intent to refer opioid dependent clients for MAT than did treatment staff. CONCLUSION: Knowledge, perceptions and information training plus interorganizational strategic planning intervention is an effective means to change attitudes and intent to refer clients for medication assisted treatment in community corrections settings, especially among corrections staff.

Implementing drug abuse treatment services in criminal justice settings: Introduction to the CJ-DATS study protocol series.

BACKGROUND: Despite a growing pipeline of effective clinical treatments, there remains a persistent research-to-practice gap in drug abuse services. Delivery of effective treatment services is especially lacking in the U.S. criminal justice system, where half of all incarcerated persons meet the need for drug abuse or dependence, yet few receive needed care. Structural, financial, philosophical and other barriers slow the pace of adoption of available evidence-based practices. These challenges led to the development of a multi-site cooperative research endeavor known as the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), funded by the National Institute on Drug Abuse (NIDA). CJ-DATS engages university-based research teams, criminal justice agencies, and community-based treatment providers in implementation research studies to test strategies for enhancing treatment service delivery to offender populations. METHODS: This Introduction reviews the mission of NIDA, the structure and goals of the CJ-DATS cooperative, and the implementation studies being conducted by the participating organizations. The component Study Protocols in this article collection are then described. DISCUSSION: CJ-DATS applies implementation science perspectives and methods to address a vexing problem - the need to link offender populations with effective treatment for drug abuse, HIV, and other related conditions for which they are at high risk. Applying these principles to the U.S. criminal justice system is an innovative extension of lessons that have been learned in mainstream healthcare settings. This collection is offered as both an introduction to NIDA's work in this area, as well as a window onto the challenges of conducting health services research in settings in which improving public health is not the organization's core mission.

A cluster randomized trial of an organizational linkage intervention for offenders with substance use disorders: study protocol.

BACKGROUND: Substance use disorders are highly prevalent in community correctional populations, yet these settings frequently are ill-equipped to identify and refer offenders to community-based treatment services. In particular, community corrections staff are often opposed to the use of medication in addiction treatment because of inadequate knowledge, resources, and organizational structures to facilitate client linkages to evidence-based services. METHODS/DESIGN: Each of the NIDA-funded Research Centers recruited 2 criminal justice agencies to participate in the study. Eligibility rules required study sites that were focused on community corrections (i.e., probation or parole), had few or no formal relationships with treatment providers for referring clients to medication-assisted treatment, and had no state or local policies prohibiting such relationships. Sites under the oversight of the same parent agency were eligible only if they were in geographically distinct catchment areas, and could be assigned to different study arms without cross-contamination at any level. The 18 clusters consisted of community corrections officers and their offender caseloads nested within agencies, each of which was partnered with at least one community-based substance abuse treatment program. Randomization was blocked by Research Center, within which one cluster was randomly assigned to a training-only condition (comparison) and the other to training followed by a strategic organizational linkage process (intervention). Line staff received a scientifically-grounded, systematically-delivered training session that addresses gaps in existing knowledge, perceptions, and information about medication-assisted treatment (MAT) and local availability of MAT services. Key decision-makers subsequently were asked to collaborate in a strategic planning process to enhance formal and informal linkages between criminal justice agencies and local MAT providers. It was hypothesized that the two implementation intervention components together would be more likely than staff training alone to improve the process of referring opioid- and alcohol-dependent adults under community supervision to appropriate addiction pharmacotherapy. Outcomes were measured at the client (referrals), line staff (attitudes), and organizational (linkage) levels. DISCUSSION: Through closer collaboration among criminal justice agencies and treatment providers, improved linkages to effective substance abuse treatment should yield significant clinical, public health and public safety benefits.

Counselor attitudes toward the use of motivational incentives in addiction treatment.

Counselor attitudes toward evidence-based practices, such as motivational incentives/contingency management (MI/CM), are important in bridging the gap between research and practice. Mailed surveys from 1,959 substance abuse treatment counselors showed ambivalence toward MI/CM and strong disagreement with using monetary rewards for achievement of treatment goals. Attitudes were associated with counselors' educational attainment, a 12-step treatment ideology, affiliation with NIDA's Clinical Trials Network, and working in opioid treatment programs. Exposure to MI/CM via training was more strongly associated with attitudes when counselors worked in programs that had adopted MI/CM. While there is substantial resistance to MI/CM, dissemination and training about the essential elements of MI/CM may enhance counselors' receptivity toward this intervention.

Modified therapeutic communities and adherence to traditional elements.

Traditional therapeutic communities (TCs) are characterized by confrontational group therapy, treatment phases, a tenure-based resident hierarchy, and long-term residential care. Many TCs have modified the structure and intensity of the traditional model, tailored services for specific client populations, and hired more professionally trained staff. This study examines the extent to which modified TCs are able to retain the underlying core technology of the TC. Using data from a nationally representative sample of 380 self-identified TCs, six traditional TC elements are identified. Results from a structural equation model indicate that offering services for specific populations and professionalization of staff has limited impact on the six TC elements. Modifications to structure and intensity of TC programming evidenced the strongest effect. Specifically, outpatient-only TCs showed significantly lower adherence to five of the six elements. Short-term residential programs showed a similar negative trend. Findings suggest selected modifications are possible without significantly impacting the TC model's core technology.

Counselor attitudes toward pharmacotherapies for alcohol dependence.

OBJECTIVE: Addiction treatment counselors play a central role in the dissemination of information about new treatment techniques to alcohol-dependent patients and are key in the implementation of new treatment technologies. Building on previous research, this study examines counselors' perceptions of the effectiveness and acceptability of pharmacotherapies for the treatment of alcohol dependence. METHOD: Mail questionnaires were received from 1,140 counselors employed in a nationally representative sample of public-sector addiction treatment programs in 2006. Counselors answered a series of questions about three U.S. Food and Drug Administration (FDA)-approved medications used in the treatment of alcohol dependence (disulfiram [Antabuse], tablet naltrexone [Revia], and acamprosate [Campral]), indicating their extent of familiarity with the medication, its perceived effectiveness in the treatment of alcohol dependence, and its acceptability for use with alcohol-dependent patients. RESULTS: The extent of diffusion of these pharmacotherapies was associated with time since FDA approval. Counselors reported receiving little or no pharmacotherapy-specific training. Multivariate models showed that the receipt of medication-specific training as well as indirect observation of the medication's use in the treatment program were significantly associated with diffusion of information about these pharmacotherapies and counselors' perceptions of the effectiveness and acceptability of the medications for use in addiction treatment. CONCLUSIONS: When exposed to information about medications to treat alcohol dependence, counseling staff appear quite receptive. More efforts are needed to disseminate information about alcohol pharmacotherapies to front-line addiction treatment staff.

Turnover intention and emotional exhaustion "at the top": adapting the job demands-resources model to leaders of addiction treatment organizations.

Compared with the large literature on subordinate employees, there are few studies of emotional exhaustion and turnover intention for organizational leaders. There is little research that has extended the job demands-resources (JD-R) model of emotional exhaustion to leaders. In this study, the authors adapted the JD-R framework to analyze data collected from a sample of 410 leaders of addiction treatment organizations. The authors considered whether two job demands (performance demands and centralization) and two job resources (innovation in decision making and long-range strategic planning) were associated with emotional exhaustion and turnover intention. The authors also examined whether emotional exhaustion fully or partially mediated the associations between the job-related measures and turnover intention. The results supported the partially mediated model. Both job demands were positively associated with emotional exhaustion, and the association for long-range strategic planning was negative. Emotional exhaustion was positively associated with turnover intention. Centralization and innovation in decision making were also directly associated with turnover intention. Future research should continue to examine this theoretical framework among leaders of other types of organizations using more refined measures of demands and resources.

Opioid treatment programs in the Clinical Trials Network: representativeness and buprenorphine adoption.

As the Clinical Trials Network (CTN) begins to focus efforts on disseminating the results of its research studies to the addiction treatment field, it is important to begin to assess the capacity of programs outside the CTN to integrate with fidelity these endorsed treatment practices. To date, no data exist to assess the representativeness of opioid treatment programs (OTPs) participating in the CTN, nor potential barriers to the effective diffusion of practices aimed at the treatment of opioid-dependent patients, including buprenorphine. Using data obtained from OTPs within the CTN (n = 49) and a sample drawn from the population of U.S. OTPs (n = 50), this study compares the two groups on their organizational, clinical, and client characteristics, as well as their adoption of buprenorphine. The study finds that the populations differ significantly on numerous variables but that structural characteristics appear more predictive of buprenorphine adoption than either staff or caseload differences. Implications for studying the diffusion and implementation of evidence-based research findings are discussed.

State policy influence on the early diffusion of buprenorphine in community treatment programs.

BACKGROUND: Buprenorphine was approved for use in the treatment of opioid dependence in 2002, but its diffusion into everyday clinical practice in community-based treatment programs has been slow. This study examines the net impact of efforts by state agencies, including provision of Medicaid coverage, on program-level adoption of buprenorphine as of 2006. METHODS: Interviews were conducted with key informants in 49 of the 50 state agencies with oversight responsibility for addiction treatment services. Information from these interviews was integrated with organizational data from the 2006 National Survey of Substance Abuse Treatment Services. A multivariate logistic regression model was estimated to identify the effects of state efforts to promote the use of this medication, net of a host of organizational characteristics. RESULTS: The availability of Medicaid coverage for buprenorphine was a significant predictor of its adoption by treatment organizations. CONCLUSION: Inclusion of buprenorphine on state Medicaid formularies appears to be a key element in ensuring that patients have access to this state-of-the-art treatment option. Other potential barriers to the diffusion of buprenorphine require identification, and the value of additional state-level policies to promote its use should be evaluated.

Clinical supervision, emotional exhaustion, and turnover intention: a study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse.

An intriguing hypothesis is that clinical supervision may protect against counselor turnover. This idea has been mentioned in recent discussions of the substance abuse treatment workforce. To test this hypothesis, we extend our previous research on emotional exhaustion and turnover intention among counselors by estimating the associations between clinical supervision and these variables in a large sample (N = 823). An exploratory analysis reveals that clinical supervision was negatively associated with emotional exhaustion and turnover intention. Given our previous findings that emotional exhaustion and turnover intention were associated with job autonomy, procedural justice, and distributive justice, we estimate a structural equation model to examine whether these variables mediated clinical supervision's associations with emotional exhaustion and turnover intention. These data support the fully mediated model. We found that the perceived quality of clinical supervision is strongly associated with counselors' perceptions of job autonomy, procedural justice, and distributive justice, which are, in turn, associated with emotional exhaustion and turnover intention. These data offer support for the protective role of clinical supervision in substance abuse treatment counselors' turnover and occupational well-being.

Research network involvement and addiction treatment center staff: counselor attitudes toward buprenorphine.

The National Institute on Drug Abuse's Clinical Trials Network (CTN) aims to improve addiction treatment in the United States in part through technology transfer. Given the importance of clinicians in the technology transfer process, this research compares 561 CTN-affiliated and 1,745 non-CTN counselors' ratings of buprenorphine acceptability. CTN-affiliated counselors reported significantly greater acceptability than non-CTN counselors. This difference was not explained by controlling for counselor characteristics, but was completely attenuated by measures of buprenorphine-specific training and buprenorphine implementation. These data suggest that the CTN's impact on counselor attitudes may be attributed to the greater exposure to buprenorphine received by CTN-affiliated counselors.

The use of antidepressant medications in substance abuse treatment: the public-private distinction, organizational compatibility, and the environment.

Many studies of innovation adoption in health care organizations focus either on organizational characteristics or the institutional environment, but not both. Furthermore, these perspectives are rarely employed simultaneously in both public and private health care organizations. This research considers the public-private distinction, organizational compatibility, and interorganizational referral relationships in the use of selective serotonin reuptake inhibitors (SSRIs) by substance abuse treatment organizations. Using data from nationally representative samples of 363 publicly funded and 403 privately funded substance abuse treatment centers, a four-category typology of public and private organizations initially predicted variation in SSRI use. However some differences were no longer significant once organizational and environmental characteristics were added to the statistical model. These data support hypotheses about the associations between organizational characteristics and SSRI use as well as hypotheses regarding the external environment. Future research should continue to integrate both internal and external factors in theoretical explanations of innovation adoption.