Results of this mixed methods study indicate that, from the perspective of the single state authorities, publicly-funded medication-assisted treatment is a priority and worthy of system-wide implementation. As of 2008, medications for the treatment of both alcohol and opioid dependence were offered in most states. Longitudinal data from 2007 to 2008 suggest that states are making strides in the implementation of addiction pharmacotherapies to varying degrees, with methadone consistently reported as the most widely adopted and utilized medication, followed by buprenorphine, naltrexone, and disulfiram, respectively. It is interesting that methadone and buprenorphine ranked as the most commonly adopted medications, despite the infrastructure barriers identified in SSA interviews. Naltrexone and disulfiram were less commonly adopted, yet are less costly and require less physician experience than the opioid substitution medications. Additionally, naltrexone and disulfiram are not “substitution” medications and are therefore not incompatible with “abstinence-only” treatment models (unlike methadone and buprenorphine). The relative underutilization of naltrexone and disulfiram, compared to opioid substitution medications, may be due to several issues. First, results with alcohol medications are less dramatic than with opioid agonists, which are self-reinforcing (Garbutt 2010
; Comer et al. 2005
). Second, disulfiram can work well in a monitored alcohol treatment program wherein the pharmacist observes medication ingestion on a daily or every-other-day basis (Brewer 1992
). Needless to say, few patients are interested in such arrangements.
In this study, and consistent with related research, many SSA representatives identified a variety of challenges to MAT access and adoption. Medication utilization appears to be inhibited by many key barriers, including policy and regulatory issues, funding or reimbursement factors, a paucity of prescribing physicians, and provider-level attitudes and beliefs about medications, specifically buprenorphine (Mark et al. 2009
; Knudsen, Ducharme & Roman 2007
; Rieckmann et al. 2007
). Accelerating the adoption of medications in substance abuse treatment requires changes in state policy, funding, provider organization, and workforce development, as well as shifts in service delivery patterns and documentation, and provider attitudes and beliefs.
Comprehensive implementation of MAT is a slow-moving process, and SSAs must identify additional strategies to further promote the increased adoption of MAT. A recent study by Wallack and colleagues (2010)
examined substance abuse treatment organizations’ adoption of buprenorphine and concluded that policies to encourage more widespread agency-level adoption of buprenorphine would be more effective if organizations focused on all three identified internal systems—technical, cultural, and political. Their findings on the impact of the cultural system on adoption, or more specifically, organizational attitudes toward the use of medications, correspond to those of the present study, in which many SSA representatives reported that there was a pervasive negative attitude toward the use of medications in substance abuse treatment or an abstinence-only philosophy that would prevent the effective incorporation of medications.
The findings of the present study, specifically those corresponding to strategies, also are consistent with research that has been conducted in the mental health setting. In a qualitative study on EBP implementation in mental health services, Magnabosco (2006)
identified five categories of strategies that can be utilized to reduce barriers to EBP implementation, including state infrastructure building and commitment, financing, and continuous quality management. Findings from the present study are consistent with these strategies to increase adoption of MAT and other EBPs. In particular, infrastructure development was positively related to prioritization and implementation of medication-assisted treatment, especially implementation of buprenorphine and naltrexone. The correlation between buprenorphine and infrastructure development may be related to the need for treatment programs to have access to a physician qualified to prescribe buprenorphine per the Drug Addiction Treatment Act of 2000 (DATA 2000
Isett and colleagues (2007)
also focused on the role of state mental health authorities in evidence-based practice implementation. Financing and regulations, leadership, and training and quality were identified as crucial factors that influence the extent to which specific clinical practices are implemented at the state level. Indeed, SSAs have multiple options to influence provider-level service delivery, including financial incentives, contract language, infrastructure development, education and training, and establishing standards or benchmarks (e.g. National Quality Forum consensus standards). However, Isett and colleagues (2007
: 920) are careful to specify that, while state authorities are key to EBP implementation, each specific practice “must be carefully selected because each of the EBPs mobilizes a different set of stakeholder groups, requires different regulations, and encounters different implementation obstacles.”
Thus the role of the SSA in treatment service delivery is significant, even pivotal, yet research on what
state policies, procedures, or strategies should be implemented and how
changes should be initiated has been limited (Magnabosco 2006
; Rapp et al. 2005
). The influence of the SSA, which is complicated at best, is driven by state structure, internal and external leadership, funding, relationships with other agencies, visibility, degree of autonomy, and communications and resource management (Gelber & Rinaldo 2005
). Results from this study confirm that the SSAs are prioritizing addiction medications and working to implement greater access, but their methods of addressing barriers often may lack a clear or systemic approach. For example, survey respondents did not reflect interdependence with other SSAs or experience with learning from networks of other providers. They often were unclear about policy implications and the most effective methods and language to use in changing administrative rules and regulations to allow for greater access to medications. Undoubtedly, resources also play a significant role in this process and, as many respondents noted, state offices remain short-staffed and underfunded in parallel with their providers. This limited human resource infrastructure also interferes with systemic change by reducing the time available to change policies, procedures, and clinical practice.
Findings from this study also correspond with the literature regarding funding, training needs, and provider acceptance of medications. Respondents repeatedly noted that a lack of resources and workforce support limited their use of medications. Similarly, Ducharme and Abraham (2008)
found that Medicaid coverage of buprenorphine is a significant predictor of adoption. Medicaid coverage also is a policy change that states must pursue by modifying their Medicaid formulary to include buprenorphine as a reimbursable treatment option (Ducharme & Abraham 2008
). In a recent review article by Garner (2009)
, receipt of training was cited as an important factor in practitioners’ acceptance of buprenorphine specifically. Proctor and colleagues (2007)
also report that training costs presented a challenge to EBP implementation in a mental health setting. Although the previous studies were focused primarily on agency directors and counselors, the present findings suggest that state officials also are concerned with similar implementation challenges.
In one attempt to prepare the addiction treatment workforce to effectively interact with individuals who were prescribed buprenorphine for opioid dependence, the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) initiated the NIDA/SAMHSA Blending Initiative (Addiction Technology Transfer Center Network 2010
; Martino et al. 2010
). Through this ongoing initiative, a Blending Team comprising NIDA researchers and Addiction Technology Transfer Center representatives was established to develop an awareness-raising training product focused on buprenor-phine. This product, entitled Buprenorphine Treatment: A Training for Multidisciplinary Addiction Professionals
(Addiction Technology Transfer Center Network 2005
) was designed to provide non-physician addiction practitioners with an overview of buprenorphine, its effects, and the role of non-physicians in providing psychosocial treatment to those individuals receiving buprenorphine. Thus, SSAs can utilize the buprenorphine-specific products that have been and continue to be developed through the NIDA/SAMHSA Blending Initiative to further raise the awareness of their providers and encourage increased implementation of this particular pharmacotherapy.
A critical next step in this area of EBP implementation research is to conduct studies that manipulate organizational and provider variables to promote the use of medication-assisted treatment. In addition, further attention to the results and implications of initiatives that are currently underway (e.g. the Robert Wood Johnson Foundation-funded Advancing Recovery program) is warranted. By promoting the adoption of evidence-based medications, SSAs continue to improve the quality of care for, and increase the menu of options available to, substance abuse treatment patients. However, given the slow uptake of medications for use in addiction treatment, past models of diffusion and implementation appear to be underdeveloped or insufficient. Although complicated and challenging, it seems that full-scale adoption will only be achieved with initiatives that address policy, regulatory, organizational, and provider-level factors simultaneously.