The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) was established in 1999 with the goal of improving drug abuse treatment through systematic scientific effort (Hanson, Leshner & Tai 2002
; O’Connor 2001
). The CTN was NIDA’s response to an Institute of Medicine report which observed that new drug abuse treatments were often developed with little regard for the needs of community treatment programs and then tested in research environments where scientific control was high but similarity to routine clinical settings was low (Lamb, Greenlick & McCarty 1998
). As a consequence, the report commented, community-based programs were slow to adopt research-based interventions.
The CTN is a national network comprising 16 research centers and more than 120 community-based treatment programs. Collaborative effort, or “bidirectionality,” is a guiding principle operationalized through equal representation of research and clinical leaders on the national steering committee, and in protocol development, planning, and implementation teams. The CTN aims to improve drug abuse treatment by determining the effectiveness of promising interventions in multisite trials, and by supporting the transfer of effective interventions into clinical practice (Hanson, Leshner & Tai 2002
Now in its tenth year, the CTN has enrolled more than 10,000 participants (CTN 2009
) into over 30 multisite studies in various stages of completion. Findings are available for randomized trials of buprenorphine (Ling et al. 2005
), contingency management (Pierce et al. 2006
; Roll et al. 2006
; Petry et al. 2005
), motivational interviewing (Carroll et al. 2006
), motivational enhancement therapy (Ball et al. 2007
), telephone-based continuing care (Hubbard et al. 2007
), HIV risk reduction intervention (Calsyn et al. 2009
), and smoking cessation (Reid et al. 2008
). To support transfer of tested interventions into practice, the CTN developed cooperative efforts with Addiction Technology Transfer Centers (ATTCs) and “Blending Teams” to disseminate CTN findings to community-based treatment settings (Whitten 2005
), and developed a series of training tools designed to support such dissemination (NIDA 2005–2007
Concurrent with the development of the CTN has been a trend toward the use of evidence-based practice (EBP) or evidence-based treatment (EBT) in drug abuse treatment. The Iowa single state authority for drug and alcohol treatment developed a plan to support community-based programs in the adoption of EBPs, with the aim of making treatment funding contingent on use of these practices (Iowa Consortium for Substance Abuse Research and Evaluation 2003
). Oregon Senate Bill 267 mandated use of EBPs in drug treatment settings and required that annually increasing proportions of all funds awarded through the state office of Addictions and Mental Health Services (AMH 2006
) be used to provide EBPs. At the federal level, the Substance Abuse and Mental Health Services Administration (SAMHSA) is expanding the National Registry of Evidence-Based Programs and Practices (NREPP) beyond its current focus on drug abuse prevention to include drug abuse treatment (Federal Register 2005
), with the goal that provider agencies can use NREPP to select EBPs (Clark 2006
). Similarly, Requests for Applications for treatment expansion funds available through the Center for Substance Abuse Treatment, popular with treatment providers, require applicants to show the effectiveness of the interventions included in their proposals.
While the NIDA CTN works to identify effective interventions, and while state and national agencies press for accountability through use of EBPs, there is increasing interest in how research-based interventions are adopted into routine practice (Glasgow, Lichtenstein & Marcus 2003
). Rogers observed that characteristics of the social system, such as its structure, norms, and decision-making processes, can affect diffusion (the process by which an innovation is communicated to others), and that characteristics of the intervention—such as trialability (how much an intervention can be used or tried in a limited way), compatibility with current practice, and complexity—influence adoption (Rogers 2003
). Management and organizational literature has conceptualized adoption of new interventions in terms of organizational change, focusing on the organization rather than the individual, and considering factors such as organizational size, communication style, and culture (Burke & Litwin 1992
). In an analysis relevant to current efforts to expand health care and to provide addiction services on parity with other healthcare services (Federal Register 2009
), Scott and colleagues (2000)
describe levels of impact on adoption that occur outside the organizational level, including the organizational set (defined by the relationship between one organization and other organizations important to its performance), organizational population (for example, drug abuse treatment programs within a specific county or state) and organizational field (including organizational populations and related agencies concerned with funding, regulation, and oversight).
Regarding the study of the adoption of addictions treatment specifically, most writings begin with Rogers’ (2003)
landmark work on diffusion of innovation, first published in 1962. Rogers drew lessons from many different fields, including substance abuse, from which he cited studies of adoption of alcoholism counseling in employee assistance programs (Fennell 1984
) and adoption of an early intervention for persons with addiction problems (Turner, Martin & Cunningham 1998
). Backer (1995)
added that availability of resources and the human dynamics of change, particularly organizational readiness for change, influence adoption. Simpson (2002)
offered a conceptual model of how innovation occurs in drug abuse treatment through the sequential steps of exposure, adoption (defined as the intention to try a new practice), implementation, and practice. In conceptualizing adoption of new interventions, each of these models suggests that adoption is more likely to occur when programs have knowledge of the intervention, are exposed to the intervention through training, and have opportunity to practice the intervention so that they can evaluate it in their own setting.
recently reviewed the literature concerning diffusion of EBTs in substance abuse and classified papers as to whether they concerned attitudes toward EBTs (25 studies), adoption of EBTs (31 studies), or implementation of EBTs (nine studies). Of the 65 papers reviewed, at least eight concerned the CTN directly or included CTN clinics as part of the sample, reflecting the contribution of the CTN to adoption literature in the area of substance abuse. Ducharme and colleagues (2007)
, for example, studied adoption of buprenorphine and motivational incentives in 1,006 programs that had differing levels of exposure to CTN studies. Some programs had participated directly in CTN clinical trials of these interventions, some were CTN programs that had not participated in these specific protocols, and some were programs outside the CTN. Programs that participated in CTN clinical trials of buprenorphine were five times more likely to report adoption of buprenorphine than were other programs, suggesting that exposure to this intervention through a CTN clinical trial may have increased buprenorphine adoption. However, this CTN exposure effect on adoption was not seen for clinics that participated in CTN studies of motivational incentives (Ducharme et al. 2007
). The difference in adoption for these two interventions may suggest that, compared to adoption of pharmacotherapy interventions, adoption of psychosocial interventions is more difficult to implement or more difficult to measure. It is also possible, however, that characteristics of the interventions themselves are more or less compatible with current practices. Use of pharmacotherapy to treat opiate addiction has a long history, whereas use of material incentives to achieve positive outcomes may have less support in addictions treatment, both in terms of practitioner attitudes and in terms of how the use of incentives can be billed and reimbursed.
Treatment programs that are involved in testing new interventions meet some of the criteria believed to be important in adoption. They can assess trialability, compatibility, and complexity of the intervention in their own setting (Rogers 2003
). They demonstrate some readiness to change when they volunteer to participate in such trials, and the trial itself provides resources for the intervention (Backer 1995
). Through the clinical trial, they gain exposure, implementation, and practice with MI/MET (Simpson 2002
). For these reasons, adoption of new treatments seems most likely in clinics that are involved in testing those treatments (Guydish et al. 2007
). There are very few studies, however, of adoption in clinics that have participated in clinical trials.
This article reports on a qualitative study of adoption in two CTN clinical trials designed to test motivational interviewing and motivational enhancement therapy (MI/MET). The overall goal was to explore the organizational level of adoption demonstrated through organizational commitment to post-trial use of the intervention, as reflected in comments by the counselor, supervisor, and director in each clinic.