2006 APHA

Attributes of Substance Abuse Organization Adopting Buprenorphine for the Office-Based Treatment of Opiate Dependence: 

Attributes of Substance Abuse Organization Adopting Buprenorphine for the Office-Based Treatment of Opiate Dependence Sarita Bhalotra, Timothy Martin, Matt Neuman, Stan Wallack Funded by the National Institute on Drug Abuse/Grant No. R01 DA014578-03 Presentation at the America Public Health Association Annual Meeting, Boston, Massachusetts Brandeis University Schneider Institute for Health Policy Heller School of Social Policy and Management November 6, 2006

Buprenorphine in Office-Based Practice: 

Buprenorphine in Office-Based Practice Drug Abuse Treatment Act of 2000: buprenorphine (Subutex®, Suboxone®) for office-based treatment of opioid addiction Legislation goal: increase access to treatment Physician certification: required Uptake: slow Previously identified barriers: lack of insurance coverage, cost, medication medication, statutory limit to the number of patients a physician can treat concurrently

Brandeis Study: Diffusion of Innovation Research: 

Brandeis Study: Diffusion of Innovation Research Uses diffusion models to examine adoption, identify barriers and predict facilitators Examines role of organizational/treatment setting factors and interaction between physicians and organizations Identifies strategies and context predictive of adoption of buprenorphine in office practice

Slide4: 

Problem: Despite proven effectiveness and successful use elsewhere, extent of buprenorphine use not as great as anticipated or desired  

Literature shows diffusion is a function of: Characteristics of Technology: proven effectiveness, availability, cost, coverage by payers, ease of administration, fit with patient typeProviders: knowledge, attitudes and behaviors: training, peer use, comfort with type of patient condition, efficacyPatients: demand/need; self-management skills, Organizations: experience with type of patient, type of technology, invested and influential leadersPolicy Environment: regulations, philosophy about patients Marketing: to organizations, prescribers, and patients: 

Literature shows diffusion is a function of: Characteristics of Technology: proven effectiveness, availability, cost, coverage by payers, ease of administration, fit with patient type Providers: knowledge, attitudes and behaviors: training, peer use, comfort with type of patient condition, efficacy Patients: demand/need; self-management skills, Organizations: experience with type of patient, type of technology, invested and influential leaders Policy Environment: regulations, philosophy about patients Marketing: to organizations, prescribers, and patients

An organization’s three internal sub-systems:: 

An organization’s three internal sub-systems: Technical: governs its treatment capacity, resources, experience and scope of services Political: differentiates power exercised by different constituencies and individuals in the organization Cultural: drives the norms and values of the organization (Tichy, 1991). These internal systems translate the force and direction of environmental pressures and drive the organization’s decision to adopt new treatments

Methods: 

Methods Survey of substance abuse organizations in 4 market areas, between September 2004 and January 2005 Of 245 eligible facilities, 87 unable to determine eligibility, 33 refuse to participate, 125 respond Response rate of 51% Of 125 organizations, 26 in Florida, 40 in Massachusetts, 26 in California, and 33 in Illinois

Survey Domains: 

Survey Domains Organization Clients Buprenorphine Medical Director Respondent

Cultural attributes: 

Cultural attributes Organizations display difference in role of medications in achieving recovery; similarity in definition of recovery as “abstinence only”

Technical attributes: 

Technical attributes Capacity, structural supports, and and experience with treating opiate addiction important in decision to adopt buprenorphine

Political: 

Political Clinician leader: influence on treatment options currently OR in the past is important Patient case-mix: more likely to prescribe to recent user, prescription drug versus street heroin user; patient with social support, stable living arrangements Demographics: organizations treating more white patients more likely to adopt

Slide18: 

Site Visits Convenience sample of six substance abuse treatment organizations in Massachusetts All treat heroin-using patients All know about buprenorphine Two use buprenophine, four do not

Slide19: 

Major findings from site visits: Role of cultural, political, and technical factors is intertwined Cultural factors dominate Trimodal distribution of treatment ideology exists (belief in medically–assisted recovery system (MARS) ; resistance to MARS, unfamiliarity or neutral attitude to MARS) Financially viable organization fulfilling its core mission is unlikely to initiate technological change Initiating technological change requires political impetus for strategic shift MARS and12-step and cognitive therapy seen as opposed

Policy explanations: 

Policy explanations Encourage markets to adopt certain products and services: regulate the nature of the product itself regulate the financial impact from the use of the product or service facilitate the consumer’s demand for the product or service (Wallack, 1991)

Slide21: 

Policy Implications: Private markets are unlikely to respond simply to legislative fiat What is the right extent of government intervention in the private market Should the intervention be placed on the demand or supply side of the market Educating providers, and the public about newer pharmacotherapeutic agents… …and harm reduction options….

Applying Matland’s Conflict and ambiguity model: 

Applying Matland’s Conflict and ambiguity model Conflict on treatment ideology (harm reduction) Ambiguity on method (medically-assisted recovery) Needs top-down implementation (political support)

Slide23: 

Learning from theory In conflictual situations, change is best accomplished by top-down implementation approach This requires resources and commitment of all implementers In our study, these are defined as the cultural, political and technical systems

Slide24: 

Visualization exercise: Imagine you are in a meadow… See three intersecting circles labeled “political”, “technical”, cultural” Now see a tornado…

Slide25: 

None of the theories (Tichy, Wallack, Matland) adequately explains decisions to adopt; successive and iterative events need to happen in order for the “tornado” to touch-down