D
Adoption of Drug Abuse Treatment Technology in Specialty and Primary Care Settings

Cindy Parks Thomas

Brandeis University

Dennis McCarty

Oregon Health and Science University

OVERVIEW

Investments in neuroscience and the development of pharmacotherapies for drug abuse treatment seem to be near fruition. Changes in federal legislation coupled with the approval of Subutex (buprenorphine hydrochloride) and Suboxone (buprenorphine hydrochloride in combination with naltrexone) for the treatment of opioid dependence offer an opportunity to engage primary care physicians directly in the treatment of dependence on heroin and other drugs. Advances in immunotherapy and depot medications are also promising. New pharmacotherapies, however, will only be effective to the extent they are accepted by clinicians and their use is facilitated through adequate financing and organizational and community support.

Newly approved pharmacotherapies are usually rapidly and widely adopted in general medicine. For substance abuse treatment, however, diffusion of medications has been a slower and less predictable process. Naltrexone for alcoholism treatment, for example, reached only a fraction of its expected market. Differences in the structure of the substance abuse treatment environment (less often built around a physician delivery model and commonly in specialty treatment settings) and differences in financing of substance abuse treatment have contributed to slower adoption of naltrexone and other such therapies. With the development of additional new pharmacological-based treatments for addictions, more individuals may be drawn to receive treatment in primary care settings. These patients often have different needs than most patients typically found in primary



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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions D Adoption of Drug Abuse Treatment Technology in Specialty and Primary Care Settings Cindy Parks Thomas Brandeis University Dennis McCarty Oregon Health and Science University OVERVIEW Investments in neuroscience and the development of pharmacotherapies for drug abuse treatment seem to be near fruition. Changes in federal legislation coupled with the approval of Subutex (buprenorphine hydrochloride) and Suboxone (buprenorphine hydrochloride in combination with naltrexone) for the treatment of opioid dependence offer an opportunity to engage primary care physicians directly in the treatment of dependence on heroin and other drugs. Advances in immunotherapy and depot medications are also promising. New pharmacotherapies, however, will only be effective to the extent they are accepted by clinicians and their use is facilitated through adequate financing and organizational and community support. Newly approved pharmacotherapies are usually rapidly and widely adopted in general medicine. For substance abuse treatment, however, diffusion of medications has been a slower and less predictable process. Naltrexone for alcoholism treatment, for example, reached only a fraction of its expected market. Differences in the structure of the substance abuse treatment environment (less often built around a physician delivery model and commonly in specialty treatment settings) and differences in financing of substance abuse treatment have contributed to slower adoption of naltrexone and other such therapies. With the development of additional new pharmacological-based treatments for addictions, more individuals may be drawn to receive treatment in primary care settings. These patients often have different needs than most patients typically found in primary

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions care and family medicine settings. Difficulties in developing linkages between primary care and the ancillary services used in addiction treatments may pose barriers to the adoption of new treatment technologies. Specialty treatment settings may also be limited in their ability or interest in adopting new pharmacotherapies due to philosophical resistance and lack of training and/or resources. This appendix applies a framework from health services research on technology diffusion to identify elements that may be important in understanding the adoption of treatment technologies in the substance abuse field. Literature on the adoption of substance abuse treatment technologies is reviewed, and particular challenges and opportunities are outlined—including the organization, financing, and delivery of specialty addiction treatments that may inhibit rapid adoption. Implications for primary care and other treatment settings are discussed relative to the availability of new pharmacology-based interventions. Finally, strategies for making these medications available and encouraging their appropriate use are examined. ADOPTION OF INNOVATIONS IN MEDICAL CARE Classical diffusion theory suggests the nature of the technology, the organizational structures and associated financial influences in which the technology is disseminated, characteristics of the providers and patients, and the communication methods (by whom and through what channels) affect the rate and direction of the adoption pattern (Banta and Luce, 1993; Office of Technology Assessment, 1994; Rogers, 1995). Figure D-1 shows a conceptual model of the factors contributing to technology adoption, described below. Technology Attributes Adoption depends in part on the attributes of the innovation and how practitioners perceive them (Meyer and Goes, 1988; Rogers, 1995). Characteristics affecting an innovation’s adoption include the relative advantages over existing technologies, whether in economic, clinical, or social terms; compatibility with values, experiences, and needs of potential users; complexity or simplicity of use; “trialability,” or the potential to try on a limited basis without significant risk; and the extent to which results are observable (Rogers, 1995). After a new technology is introduced, uncertainty often remains regarding its use. Emerging technologies are commonly used in ways other than initially intended (Gelijns and Rosenberg, 1994). Modification of the technology occurs after initial adoption (Greer, 1988),

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions FIGURE D-1 Conceptual model for adoption of new substance abuse pharmaceutical technologies. SOURCE: Adapted from Thomas et al. (2003). Reprinted by permission of the publisher.

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions and uneven use occurs at a high rate early in the diffusion process (Wennberg, 1988). While similar diffusion patterns exist for medications, devices, and surgical procedures, medications may have a lower adoption “threshold”—it is easier to write a prescription than learn a new procedure or approach (Fendrick and Schwartz, 1994). While medications and devices must first gain approval from the Food and Drug Administration for use in general clinical practice, different combinations and uses of pharmacotherapies in practice are not well evaluated (Sisk and Glied, 1994), and uses by physicians of medications on the market for indications or in combinations other than that for which they received FDA approval (so-called off-label prescribing) is thought to be common. Although physicians are able to prescribe medications upon FDA approval, a number of factors may inhibit adoption. Innovations that depart from existing practices and are counter to prevailing attitudes are much less likely to be adopted (Office of Technology Assessment, 1994). Physicians may reject new medication therapy because of what it might do to the physician’s case mix, because other practice costs will rise, or because of inadequate time for patient visits. They may also reject a new therapy if there is inadequate evidence of cost-effectiveness (particularly in comparison to existing approaches). In summary, immunotherapy and depot medications can present promising new strategies for treating drug dependence and abuse if they have potential relative advantage over existing treatments, compatibility with current drug treatment practices, and both providers and patients find them easy to use. But it is likely that ways in which clinicians and treatment settings perceive the new interventions will affect adoption. Provider Attributes Members of the social system and professional networks are an important element in the diffusion process (Rogers, 1995). Typically in general health care, exponential growth in the use of new treatments often ensues in an “epidemic” pattern throughout the larger provider community, as information disseminates regarding the new technology through professional networks, media, and advertising and following positive reports from initial users and demand from patients. However, at the same time, if incentives, education, and resources are not in place to adopt new treatment strategies, physicians can be somewhat resistant (Eisenberg, 1993). Research has examined the characteristics of individuals associated with innovation as independent practitioners (Kimberly and Evanisko, 1981) and as leaders of organizational policy (D’Aunno, Vaughn, and McElroy, 1999; Friedmann, Alexander, and D’Aunno, 1999b). Variables

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions including younger age (Alexander et al., 1997; Counte and Kimberly, 1974), more education (Rogers, 1995), more urban practice, higher certification, specialization (Alexander et al., 1997; Counte and Kimberly, 1974; Rogers, 1995), academic affiliation, and group rather than individual practice were associated with earlier adoption of new technologies (Coleman, Katz, and Menzel, 1966; Fendrick and Schwartz, 1994; Freiman, 1985). Decisions to adopt have also been linked to factors such as authority roles among peers and the relationships of providers within an organization (Posner, Gild, and Winans, 1995). Studies of physicians’ prescribing behavior suggest that the decision to write a prescription is a complex process, influenced by organizational rules, training, treatment philosophy, experience, information, and opinion leaders. Physician characteristics (Dybwad et al., 1997), provider assessments of the need for a prescription, likelihood of patient compliance, and the likely outcome of treatment (Brown et al., 1997; Denig, Haaijer-Ruskamp, and Zijsling, 1988; Lambert et al., 1997; Turk and Okifuji, 1997) do not fully explain variations in prescribing patterns. Advertising, education, and patient demand also affect prescribing patterns (Hemminki, 1975). Organizational Structures and Financing of Treatment The organization, its internal structure, and its response to external influences, such as competition or reimbursement on rates of technology acquisition and use affect adoption (Escarce et al., 1995; Hodgkin and McGuire, 1994; Romeo, Wagner, and Lee, 1984; Teplensky et al., 1995). Factors that are positively associated with earlier and more thorough adoption of innovation include size (Moch and Morse, 1977), resources (D’Aunno et al., 1999; Nohria and Gulati, 1995), academic network, leader behavior (Becker, 1970; Chilingerian and Glavin, 1994), system openness, organizational slack, a more competitive marketplace, and favorable reimbursement for the innovation. Thus, having resources available to explore and adopt a new innovation and having leadership with interest in and commitment to innovation are important factors in technology adoption. The treatment setting’s environment—that is, “the specific collection of organizations providing the critical sources of inputs, and markets for outputs, required for an organization’s survival” (Scott, 1993, p. 292)—includes its competitors, state and federal regulators, parent organizations, managed care organizations, pharmaceutical companies, and potential clients. Each group exerts different demands or poses particular threats or incentives to the focal treatment setting that may drive it to adopt and encourage or reject and discourage new pharmacotherapies for drug de-

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions pendence (see Strang and Soule, 1998). Thus, managed care organizations and insurers may promote adoption of new pharmacotherapies by including them in the formulary or by issuing treatment guidelines that advocate their use. States can encourage the use of particular medications by covering treatment under Medicaid benefits. Regional location may influence decisions to accept and encourage pharmacotherapy in addiction treatments. Methadone treatment units in the northeastern United States used more effective treatment practices than those in other regions (D’Aunno and Vaughn, 1992). This may be due to the high concentration of top-tier medical schools and academic health centers in the area and the resulting exposure to and competition to remain at the cutting edge of medical science. Other treatment organizations may influence the decision to adopt particular medications, particularly if competitors have done so (Abrahamson, 1991; DiMaggio and Powell, 1988; Tolbert and Zucker, 1983; Westphal, Gulati, and Shortell, 1997). Professional organizations (e.g., American Society of Addiction Medicine) may improve an organization’s appraisal of immunotherapy and depot medications through official endorsements and dissemination of information about treatments. Pharmaceutical companies may also encourage adoption through marketing campaigns, particularly direct and repeated marketing to the focal organization (Van den Bulte and Lilien, 2001). If a pharmacotherapy is perceived as a cost-effective treatment or a highly effective treatment, superior to other methods, organizations will experience substantial pressure to adopt it in order to enhance their performance and compete with other treatment organizations for individual and group clients (i.e., managed care contracts, state contracts). Cultural attitudes toward new pharmaceuticals in treatment will drive the pressures from the institutional environment. A shared view that pharmacotherapy represents the cutting edge of treatment for drug dependence may encourage physicians and organizations to adopt new pharmacotherapies in order to enhance their reputation or increase their market. Alternatively, if professional organizations and treatment organizations begin to accept these innovations, others may follow and come to view accepting particular new pharmacotherapies as a necessary move. Channels of Communication Channels of communication influence what information is transferred to potential users and its credibility. Professional information regarding a technological innovation is generally transferred in several ways, both formal (scientific literature, meetings, training) and informal (opinion leaders, colleagues, advertising, and press reports). However, while scientific evidence is an important factor, most adoption decisions depend

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions on the transfer of subjective information regarding the treatment from one member of a group who has already tried the innovation to another person in the group (Rogers, 1995). The change agent tends to be most effective when it is someone much like the potential adopter. A major method of communicating information regarding new pharmaceuticals that has been particularly effective is marketing by drug manufacturers. In recent years the medications with the greatest growth in sales have been those that have been heavily marketed (National Institute of Health Care Management, 2002). However, marketing of prescription drugs can be a double-edged sword: While the message regarding the availability of new pharmacotherapies has been effectively communicated and can reach new potential audiences, information provided by manufacturers may be biased and must be complemented by additional objective sources. Further, there is some concern that extensive marketing efforts in the case of new medications in general medicine can lead to overprescribing and inappropriate use (Altman and Thomas, 2002). However, in the case of new drug treatment pharmacotherapies, marketing efforts, which are known to be a powerful driver of adoption of new medications, may be limited by how manufacturers perceive the profitability of new treatments. The transtheoretical stages-of-change model (Prochaska and DiClemente, 1983) provides an additional framework for assessing behavioral changes and communication strategies. Adoption of innovations is viewed as a multistep process, integrating the practice setting and an ability to move through a continuum of five steps: precontemplation (no knowledge yet regarding the action), contemplation (awareness of the new behavior and motivation to adopt), action (development of a strategy to use the technique), implementation of the technique, and maintenance. Rather than examine the structural characteristics of a health care system, studies assess organizational and individual readiness to accept new treatment strategies (Backer, 1995). Investigators focus on the dynamics of the change process in order to understand differences between early- and late-adopter individuals and organizations and to improve technology transfer. Studies of cancer screenings and treatments (Johnson, Warnecke, and Aitken, 1996; Kaluzny et al., 1990) and cessation of addictive behaviors (Prochaska et al., 1994) illustrate the model’s broad base of support and the value of matching interventions with readiness to change. Summary Rogers’s (1995) framework for the diffusion of technology and the transtheoretical model of change provide structures for disaggregating the process of diffusion and analyzing critical components. The adoption

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions of pharmacotherapies for the treatment of drug abuse disorders, particularly in primary care, may be particularly sensitive to the characteristics of the medication (compatibility, complexity, and observability), the use of people in recovery as change agents, analyses of the persuasion process, and the nature of the social and organizational systems found in drug treatment programs. While the historical pattern in the United States is that of relatively rapid adoption of new pharmacotherapies, there are reasons to believe that the adoption of medications to treat drug and alcohol dependence will be more reserved. The use of medications as complementary interventions with behavioral therapies represents a vast change in the nature of treatment of drug abuse challenging current practitioner and provider structures. Multiple professional and social obstacles may offset the easy “trialability” of pharmacotherapy. Furthermore, to the extent that substance abuse treatment medications are used to enhance the efficacy of existing therapies, they may significantly contribute to increased costs of addiction treatment. The literature on adoption of technology in alcohol and drug abuse treatment may be informative. ADOPTION OF TECHNOLOGIES IN THE TREATMENT OF ALCOHOL AND DRUG ABUSE The peer-reviewed literature on the adoption of new technologies in alcohol and drug abuse treatment settings is surprisingly limited; systematic empirical investigations are uncommon. A review of the literature finds one randomized trial of dissemination methods, a few analyses of the adoption of naltrexone for the treatment of alcohol dependence, and a handful of essays reflecting on barriers to adoption and strategies to address the barriers. Randomized Trial A randomized trial tested dissemination strategies to promote an evidence-based practice to improve employment among patients in drug treatment (Job Seekers Workshop; Sorensen et al., 1988). Drug treatment programs (n = 172) were randomized to four levels of information about the employment training intervention: (1) training materials only (i.e., a 20-page summary of the workshop and effectiveness data plus a manual on conducting the workshop), (2) the training materials plus one day of on-site technical assistance, (3) the training materials plus an expenses-paid 2-day training, and (4) a nonintervention comparison where training materials were provided after the follow-up period. A questionnaire mailed three months after the interventions assessed the extent to which the training materials had been used and the number of workshops con-

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions ducted. Adoption was higher among programs that received a technical assistance site visit (28 percent) or participated in the 2-day training (19 percent) than at the sites that received only printed materials (4 percent) and among programs in the nonintervention group (0 percent). Hands-on, in-person demonstrations appear to be an important element in the adoption of new drug abuse treatment interventions. Despite the strength of the finding, dissemination efforts continue to emphasize distribution of brochures and manuals. The Sorensen et al. study remains the only randomized trial that tested interventions to promote the adoption of an empirically supported drug abuse treatment technology. Subsequent investigations examined differences between practitioners who adopted or did not adopt new technologies and provide useful insights into variables associated with adoption. But in the absence of random assignment, multiple factors may contribute to the observed differences in adoptions. Adoption of Naltrexone Using naltrexone for the treatment of alcohol dependence remains an intriguing example of limited adoption of a medication for addiction treatment. A mail survey conducted in Massachusetts, Tennessee, and Washington state among physicians with a substance abuse specialization (135 responses, 63 percent response rate) and certified addiction counselors (1,116 responses, 65 percent response rate) found limited use of naltrexone (Thomas, 2000; Thomas et al., 2003). Most (80 percent) of the physicians reported current or prior use of naltrexone, but only 15 percent prescribed it often (11 percent) or for almost all patients (4 percent). A majority (54 percent) of counselors, in contrast, had never suggested use of naltrexone to patients, and few recommended it often (4 percent) or for almost all of their patients (1 percent). Logistic regression models suggested that adoption was more likely among physicians involved in research (odds ratio = 19.7) and physicians located in organizations that promoted the use of naltrexone (odds ration = 11.6). Physicians in recovery (odds ratio = 0.2) and physicians with multiple degrees (odds ratio = 0.1) were less likely to prescribe naltrexone. Organizational support to use naltrexone was the strongest influence on counselors recommending it to patients (odds ratio = 7.9). Counselors who reported receiving marketing information on naltrexone were also more likely to recommend its use (odds ratio = 3.2). Patient access to insurance that covered naltrexone also affected counselor behavior. Counselors with a higher proportion of Medicaid patients were more likely to prescribe naltrexone, and those with more patients funded through block grant and self-pay were less likely. (Medicaid in all

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions three states covered naltrexone prescriptions, while block grant funding did not pay for it.) Washington state actively encouraged counselors to support the use of naltrexone, and counselors in Washington (compared to Massachusetts and Tennessee) were more likely (odds ratio = 1.5) to recommend that their patients use naltrexone. Recovery status did not have a significant influence on counselor use of naltrexone. Overall, these results suggest that organizational support, financing mechanisms, and state policies may influence the adoption of medications to treat alcohol and drug abuse. Roman and Johnson (2002) examined organizational influences on the adoption of naltrexone. In a sample of 400 alcoholism treatment centers, 44 percent reported current use of naltrexone. Levels of use among patients, however, were low among both alcohol- (13 percent of the caseload) and opiate-dependent (11 percent of the caseload) patients. Logistic regression suggested that any naltrexone use was greatest in centers where counselors were more likely to have master’s degrees (odds ratio = 1.7) and with more patients in commercial health maintenance organization and preferred provider organization health plans (odds ratio = 1.02). Centers that were older and those with higher caseloads of patients with a history of relapse also were more likely to use naltrexone. Importantly, structural characteristics of the organization (e.g., hospital setting, larger corporation, physician availability) were not significant influences when tested in multivariate models. The investigators suggest that addiction treatment programs have not encountered rapid change in technology, so older, more experienced programs and administrators are more willing to assume the risk of adoption. They also noted that levels of education among clinical staff are a key factor in the adoption of naltrexone but that the overall magnitude of use is still minimal (Roman and Johnson, 2002). In a Researcher in Residence Program piloted in New York state, nationally recognized investigators provided hands-on technical assistance to facilitate adoption of research-based technologies for alcoholism treatment (Hilton, 2001). Investigators provided one to three days of on-site assistance and at three sites either a reconnaissance visit or a booster session. Participating programs requested assistance with the use of naltrexone (two sites), clinical assessment (two sites), motivational interviewing (one site), and services for patients with comorbidities (one site). Interviews with program directors and clinical staff were conducted three to six months after visits to assess impacts and adoption. Case studies were prepared for each of the six sites, and commonalities were abstracted. Hilton (2001) concluded that the site visits fostered adoption but that organizational change is difficult, takes time, and requires sustained leadership. The Researchers in Residence Program provided clinical staff with opportunities to have personal experience with the new technolo-

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions gies, and that experience seemed to promote adoption and use. Staff turnover, however, inhibited follow-through and adoption was observed in some but not all of the clinical settings. When adoption required more change in practice style, change was slower and less likely to be observed in a short follow-up. Surprisingly, limited reimbursement for prescription medications and negative staff attitudes toward the use of medications did not inhibit the use of naltrexone (Hilton, 2001). The results of the Researcher in Residence Program echo the findings from Sorensen et al. (1988)—hands-on technical assistance is often an essential aspect of adopting a new treatment technology. Essays on Adoption The most common, but still infrequent, papers on the adoption of technologies in addiction treatments are personal reflections on variables that contributed to or inhibited adoption of evidence-based drug abuse treatment technologies. Brown’s thoughtful essays review linkages between research and practice, lament the lack of strategies to foster technology transfer, and encourage adoption of research findings (Brown, 1987, 1995, 1997, 1998, 2000; Brown and Flynn, 2002). Backer summarizes the technology transfer and dissemination literature and generalizes from classic work on technology diffusion to the adoption and use of drug abuse prevention and treatment technologies (Backer, 1991, 1995; Backer and David, 1995; Backer, Rogers, and Sopory, 1992). Naranjo and Bremner describe their efforts and frustrations implementing the use of a clinical tool (the Clinical Institute Withdrawal Assessment for Alcohol) to improve detoxification services in rural areas of Canada (Naranjo and Bremner, 1996). Similarly, Morgenstern (2000) reflects on his experiences promoting the use of cognitive behavioral therapies in traditional 12-step treatment settings. Most recently, the focus has shifted toward viewing technology transfer as a process of organizational change. The Addiction Technology Transfer Centers promote an organizational change model to support the adoption of evidence-based practices in alcohol and drug abuse treatment centers. The Change Book offers a 10-step structure to foster organizational change and support the adoption and use of new drug abuse treatment technologies (Addiction Technology Transfer Centers, 2000). Finally, in a promising development, Simpson (2002) reviews the literature on technology transfer and drafts a model of the factors that contribute to organizational change and the adoption of new technologies for drug abuse treatment; early results are encouraging. It is critical, therefore, to have an overview of the financing and organization of specialty drug and alcohol treatment programs.

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions financial resources to address problems of substance abuse, and the stigma often associated with patients who have addiction problems. Additional challenges in promoting linkages between primary and specialty services include difficulties communicating across settings, confidentiality standards for the treatment of alcohol and drug disorders that often inhibit sharing medical and psychosocial information, and concerns regarding coerced treatment. Confidentiality Regulations Alcohol and drug abuse treatment records have a unique level of federal protection. In most cases, information in the clinical record may not be shared without the specific consent of the patient. Authority for confidentiality standards for alcohol dependence treatment records was included in the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (Hughes Act, P.L. 91-616) and extended to drug abuse treatment records in the Drug Abuse Prevention, Treatment, and Rehabilitation Act of 1972 (P.L. 92-255; Lopez, 1994). The regulations were designed to protect the privacy of individuals entering care (Legal Action Center, 1991). The strict confidentiality requirements prohibit disclosure of information from a “federally assisted” treatment program unless the patient provides a valid consent to the release or specific conditions are met for a court-ordered release (Legal Action Center, 1991). “Federally assisted” is broadly defined to include any form of federal funds, a grant of tax-exempt status, an authorization to conduct business, or an agency of federal, state, or local government. As a result, the rules apply to all facilities that are licensed or authorized by state regulations. State regulations may be more restrictive but cannot permit disclosures that are prohibited by the federal regulations. The strict limits on disclosure are unique to alcohol and drug abuse treatment programs. Medical records and mental health records do not enjoy the same level of protection. As a result, primary health care practitioners may be unaware that their patients are simultaneously receiving treatment for alcohol and drug disorders. The confidentiality regulations complicate efforts to integrate care. The recent implementation of stricter confidentiality standards for medical records (Health Insurance Portability and Accountability Act) does not obviate the stricter standards applied to alcohol and drug abuse treatment records but may foster consistent strategies for releasing and sharing information, including treatment for alcohol and drug disorders in health care settings.

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions Financing Differences in financing between general medical care and mental health/substance abuse treatment will also challenge adoption of new treatments. First, many insurance programs limit funding for counseling and recovery support. Second, in cases in which care is fully or partially capitated (either all services or carved out to specialty substance abuse programs), new medications and treatments may need to prove they are cost effective in order to be adopted onto formularies and incorporated into treatment. Chronic Care Model A valuable approach to the management of addiction treatment in primary care settings would be to apply principles of optimal chronic disease management. A recently demonstrated approach to managing chronic illness was applied to tobacco addiction (Bodenheimer, Wagner, and Grumbach, 2002a, 2002b). This model recognizes and operationalizes linkages across the systems in which chronic care takes place—community resources and health care, financing, and provider organizations. Proactive teams address six essential elements of care: community resources and policies, health care organization, self-management support, delivery system design, decision support, and clinical information systems. The chronic care model improved outcomes of care and in some cases reduced costs for certain conditions. However, payment incentives are not always in alignment with the chronic care model approach and can provide obstacles to coordination of care. Emergency Medicine Finally, the emergency medical setting must be considered a potential setting for adoption and implementation of immunotherapies or depot medications. The prevalence of substance abuse in emergency room patients is estimated at 15 to 24 percent (Teplin, Abram, and Michaels, 1989; Cherpitel, 1996). Emergency personnel, however, detect and refer only a small proportion of substance abuse problems (Fortney and Booth, 2001). As treatment options for overdose and relapse prevention increase, physicians and hospitals will have to make decisions to adopt interventions that may require better detection of drug dependence. Protocols will have to be developed and individualized to the particular setting. Some issues in emergency care may be the same as those of primary care, in particular lack of training specific to addiction problems and inadequate

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions linkages or follow-up for individuals treated in emergency rooms. Additional barriers are specific to emergency departments: A high proportion of emergency care is uninsured, so reimbursement for expensive interventions will be difficult to obtain. Many individuals treated in emergency departments are lost to follow-up, so linkages to care will be critical. Prioritizing and triaging patients are important components of emergency care, but some individuals being treated for addictions may receive lower priority than others needing urgent care. Thus, the adoption of immunotherapies and depot medications will be challenging whether in specialty settings, primary care, or emergency medicine. CONCLUSIONS Extensive literature indicates that adoption of innovations is the result of characteristics of the provider, treatment setting, financing strategies, the technology itself, and the manner in which information is communicated. Several characteristics of the substance abuse treatment system have in the past worked to diminish the speed and extent to which innovations have been adopted in addiction treatment. Addiction treatment technologies have achieved less than anticipated success in the market, most recently in the case of naltrexone, where financing, education, and questions regarding effectiveness have played a large part in the lack of adoption. Studies suggest that many of the barriers to adoption of new substance abuse treatments may be amenable to policy interventions, including appropriate education, adequate financing, and improved linkages between primary care and specialty treatment. Specific approaches to technology transfer can promote new therapies for drug abuse treatment and may have particular significance for the successful diffusion of depot medications and immunotherapies. These innovations have the potential to reach a wide population at need and bring primary care settings to play a greater role in addiction treatment. However, in order to do so, policy makers and providers must influence financing strategies, organizational structures, and educational approaches that will facilitate use of these innovations. See Figure D-1 for a summary of the health care system components that must be addressed to promote appropriate adoption of immunotherapies and depot medications for the treatment of drug dependency disorders. Integration of treatment of substance abuse disorders is not universally implemented in primary care. However, research suggests that

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New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions several factors can facilitate appropriate and informed use of new medications. These strategies can be considered prior to widespread availability of immunotherapies and depot medications. A necessary step prior to making immunotherapy and depot medications available is to develop professional standards that guide the application of the therapies to specific patient groups, including adolescents. Guidelines for prophylaxis are also needed. Several areas have made progress in the development of practical guidelines for screening and treatment. Particularly effective are alcohol screening tools and smoking cessation programs. These approaches, however, must be applied regularly in practice in order to be effective. Therefore, an accompanying approach is provider education. It is clear from the literature that multi-faceted education efforts for physicians and other providers must be in place to inform them about all aspects of the use of these therapies. As has been shown with naltrexone, a lack of information supported a host of other questions surrounding the drug’s effectiveness, and adoption in primary care has been negligible. On the other hand, in the case of buprenorphine, a multipronged approach is taking place in which guidelines are being developed by the federal government, providers are being certified through professional societies to treat patients in office settings, it is being incorporated on formularies, and patient education materials are being developed. The importance of linkages between primary care and related support services is being addressed, although it presents a continuing challenge. How this pharmacotherapy is addressed in primary care, and how this innovation may affect the treatment of substance abuse disorders, will be important to document. Education directed toward providers must be complemented by efforts to educate the public regarding both the chronic disease nature of addiction disorders and the importance of screening and treatment. With regard to immunotherapies and depot medications that may be available for prophylaxis, particular problems may arise regarding appropriate use and public perceptions surrounding this approach to management. Additionally, insurance and financing are necessary components of successful adoption of any therapy into practice. It is essential to understand the structure of the market for immunotherapies and depot medications, so that manufacturers’ efforts to promote these medications can be balanced by objective information from other sources. It is important to note that financing for substance abuse treatments occurs through various avenues in the public and private sectors. While inclusion on insurers’ formularies is important for the private sector, funding through public programs at the federal and state levels is essential after a medication becomes available.

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