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									     STATE POLICIES &
AVAILABILITY OF INFECTION-
   RELATED SERVICES IN
SUSTANCE ABUSE TREATMENT
PROGRAMS – CONNECTED AT
           THE HIP?

  The NIDA Clinical Trials Network
  Infections Study (CTN-0012)
Lawrence S. Brown, Jr., MD, MPH, FASAM;
Steven Kritz, MD; John Rotrosen, MD; Jeff
Goldsmith, MD; Edmund Bini, MD, MPH; Jim
Robinson, MEd

Addiction Research & Treatment Corp,
Brooklyn, NY; NYU School of Medicine and
VA Hospital, NY, NY; University of
Cincinnati Medical Center, Cincinnati, OH;
Nathan Kline Institute, Orangeburg, NY
     ACKNOWLEDGEMENTS
• Research Supported by National Institute on Drug
  Abuse (NIDA) as part of a Cooperative
  Agreement (1U10DA013046) with the NIDA CTN
  and other Protocol Team members consisting of:
  – Randy Seewald, MD; Cheryl Smith, MD; Frank McCorry,
    PhD; Dennis McCarty, PhD; Donald Calsyn, PhD;
    Leonard Handelsman, MD; Steve Kipnis, MD
  – Patrick McAuliffe, MBA, LADC; Al Hassen, MSW;
    Karen Reese, CAC-AD; Sherryl Baker, PhD
  – Shirley Irons; Kathlene Tracy, PhD
Drug Abuse Treatment Clinical Trials Network
17 Nodes with 116 Community Treatment Agencies
            Reaching into 26 States!
     Seattle



    Portland

                                                       Detroit   New York
                                                                   City         Boston
                                                                               New Haven
                       Denver                                                  Long Island
                                                  Cincinnati               Philadelphia
       San Francisco
                                                                         Baltimore/Richmond
       (CA/AZ Node)


           Los Angeles          Albuquerque                         Raleigh/
                                                                    Durham

                                                                 Charleston




                                                                 Miami



                                              CTN Sites
       STUDY RATIONALE
• HIV/HCV/STI: major causes of excess
 morbidity and mortality in the US
• Substance abuse: a major vehicle for the
 transmission of infection
• Scope of, and challenges to identifying,
 counseling and treating persons with
 these infections in substance abuse
 treatment will assist in developing
 effective interventions
    IMPORTANT ABREVIATIONS
•   AIDS = Acquired Immunodeficiency Syndrome
•   HIV = Human Immunodeficiency Virus
•   HCV = Hepatitis C Virus
•   STI = Sexually Transmitted Infections
•   CTP = Community Treatment Program
•   CTN = Clinical Trials Network
•   SOP = Standard Operating Procedures
•   IRB = Institutional (Human Subject) Review Board
           IMPORTANT TERMS
• Treatment Program vs. NIDA CTN CTP
• Services Assessed
  – Provider Education
  – Patient Education
  – Patient Risk Assessment
  – Patient Medical History & Physical Exam
  – Patient Biological Testing
  – Patient Counseling
  – Patient Treatment
  – Patient Monitoring
     PRIMARY OBJECTIVES
• TO DESCRIBE:
 – Range of Infection-Related Services Available
 – CTP Characteristics (funding, staffing)
 – Perceived Barriers to Providing Infection-Related
   Services
 – State Regulatory Guidelines
• TO EXAMINE ASSOCIATIONS BETWEEN:
 – CTPs’ Availability of Selected Infection Services
 – Other Constructs Listed Above
DESIGN AND POPULATION
• STUDY DESIGN
  – 2 Cross-sectional Surveys
  – Descriptive & Exploratory
• STUDY POPULATION
  – CTP Administrators
  – Administrators of State Health Departments
    and Substance Abuse Agencies
   ETHICAL, REGULATORY
   AND ADMINISTRATIVE
     CONSIDERATIONS

• Expedited IRB Approval
• Waiver of Informed Consent
• Training for Node Protocol Managers
                     Administrator Surveys
                                                                                                 Administrator completes
                           Contact CTP Directors for            Survey materials                 survey online or mails to
   Ensure
                           Treatment Program and                mailed to                        Data Center;
   IRB
                           Administrator contact                Administrators                   Administrator enters
   approval
                           information                                                           contact information for
                                                                                                 Clinicians

Data Center contacts Administrators
                                                  Node Protocol Manager contacts
that have not completed the survey
                                                  Administrators that have not responded
or Clinician contact information                                                                      Data Center
                                                  within two weeks
within 30 days                                                                                        contacts
                                                                                                      Administrators
                                                                                                      to resolve any
                                                                                                      data queries

                                                                        After four weekly
  For Administrators that                    Node Protocol
                                                                        attempts,
  refuse to participate or still             Managers
                                                                        Administrators flagged
  have not responded after                   contact non-
                                                                        as non-responders by
  two additional weeks, the                  responder
                                                                        the Data Center
  Node Protocol Manager                      Administrators
  alerts the Node Principal                  weekly
  Investigator
                            State Surveys
  Project Manager
  enters State                 Data Center mails       State Administrator
  Administrator                survey material to      completes the survey
  contact information          State                   online or mails to Data
  into the Data                Administrators          Center
  Center system




After four weekly
                               Project Manager      Data Center reviews data
attempts to contact
State Administrators, the      contacts State       and communicates any
                               Administrators       issues to Project Manager
Project Manager flags
them as non-responders         that have not
                               completed survey
                               within 30 days


                                                    Project Manager
                                                    contacts State
                                                    Administrators to
                                                    resolve data queries
  STATISTICAL ELEMENTS
• Sample Size and Precision of the
  Estimated Mean
• Analytic Plan
  – Descriptive stats for survey variables
  – Principal Component or Cluster or Factor
    Analysis to group and reduce the number of
    variables
  – Structural Equation Models to test for
    associations
              RESULTS
• 269 out of 319 (84%) substance abuse
  program administrators responded
  administrators.
• At least one health department or
  substance abuse agency administrator
  from 48 states and the District of
  Columbia (96%) responded
    Characteristics of Treatment Programs
    Characteristic             Number of Surveys with      Number (%) of
                                  Valid Responses       Treatment Programs*
Corporate structure
 Private not-for-profit                268                   212 (78.5)
 Private for profit                                           15 (5.6)
 Government
                                                              36 (13.4)
 Other
                                                               6 (2.2)
Largest source of revenue
County/local grants                    269                    45 (16.7)
 State funds                                                 103 (38.1)
 Medicaid
                                                              46 (17.0)
 Federal grants
 VA Benefits                                                  33 (12.2)
 Medicare                                                      5 (1.9)
 Private contracts/insurance                                   4 (1.5)
 Self-pay                                                      9 (3.3)
 Other                                                        15 (5.6)
 Unknown                                                       3 (1.1)
                                                               7 (2.6)
*Percentages do not total 100% due to rounding and non-respondents
     Characteristics of Treatment Programs
        Characteristic                       Number of Surveys with   Number (%) of
                                                Valid Responses         Treatment
                                                                       Programs*
Patient census                                        250
 ≤500                                                                    145 (53.9)
 500 – 1000                                                              52 (19.3)
 >1000                                                                   53 (19.7)
Addiction Services Offered #
                                                      256                148 (55.0)
 Inpatient or residential services
                                                      242                89 (33.1)
 Outpatient pharmacotherapy
                                                      257                206 (76.6)
 Other outpatient services
                                                      259                227 (84.4)
 Outreach & support services
   Medical Staff                         0                               55 (20.4)
                                         1                               31 (11.5)
                                       2-3                               64 (23.8)
                                       4-7                               54 (20.1)
                                        8+                               57 (21.2)
   Non-Medical Staff                   0-7                               79 (29.4)
                                      8-11                               59 (21.9)
                                     12-17                               59 (21.9)
                                       18+                               64 (23.8)

*Percentages do not total 100% due to rounding and non-respondents
# Responses were not mutually exclusive for this item
  HIV/AIDS, HCV & STI-RELATED SERVICES
PROVIDED IN SUBSTANCE ABUSE TREATMENT
    PROGRAMS WHEN STATE MANDATED
                     HIV/AIDS     HCV        STIs
                      n (%)      n (%)      n (%)
Provider Education    137 (77)   113 (69)   113 (64)
Patient Education     218 (90)   140 (80)   154 (84)
Risk Assessment       180 (91)   147 (79)   140 (82)
History & Physical    67 (59)    62 (57)    58 (54)
Examination
Biological Testing    65 (52)    48 (43)    53 (47)
Counseling            137 (72)   93 (73)    75 (70)
Treatment             66 (59)    38 (56)    42 (51)
Monitoring            44 (72)    38 (69)    43 (70)
RELATIONSHIP BETWEEN STATE MANDATES &
 PERCENT OF SUBSTANCE ABUSE TREATMENT
PROGRAMS PROVIDING HIV/AIDS, HCV & STI-
     RELATED BEHAVIORAL SERVICES


INFECTION     STATE     PATIENT       RISK      COUNSELING
            MANDATED   EDUCATION   ASSESSMENT
HIV/AIDS      YES        90%          91%          72%
              NO         88%          79%          71%

  HCV         YES        80%          79%          73%
              NO         75%          65%          52%

  STIs        YES        84%          82%          70%
              NO         70%          65%          59%
  HIV/AIDS, HCV & STI-RELATED SERVICES
PROVIDED IN SUBSTANCE ABUSE TREATMENT
  PROGRAMS WHEN NOT STATE MANDATED
                     HIV/AIDS    HCV       STIs
                      n (%)     n (%)     n (%)
Provider Education    48 (65)   57 (65)   41 (54)
Patient Education      7 (88)   58 (75)   49 (70)
Risk Assessment       42 (79)   45 (65)   53 (65)
History & Physical    60 (59)   54 (50)   57 (51)
Examination
Biological Testing    66 (54)   45 (32)   56 (39)
Counseling            39 (71)   65 (52)   87 (59)
Treatment             37 (27)   40 (25)   50 (29)
Monitoring            72 (39)   57 (29)   62 (32)
  RELATIONSHIP BETWEEN STATE
MANDATES & PERCENT OF SUBSTANCE
  ABUSE TREATMENT PROGRAMS
 PROVIDING HIV/AIDS, HCV & STI-
   RELATED MEDICAL SERVICES
INFECTION     STATE    HISTORY &   TREATMENT   MONITORING
            MANDATED   PHYS EXAM

HIV/AIDS      YES        59%         59%          72%
              NO         59%         27%          39%

  HCV         YES        57%         56%          69%
              NO         50%         25%          29%

  STIs        YES        54%         51%          70%
              NO         51%         29%          32%
           SUMMARY
• Most HIV/AIDS, HCV & STI-related
 services are offered by:
  – a substantial proportion of private not-for-
    profit, for-profit, and public agencies
  – a substantial proportion of substance abuse
    treatment programs of all sizes
• Staffing patterns (medical and non-
 medical) are quite varied
          SUMMARY
• Six of eight targeted services were
  provided by a similar % of programs,
  regardless of state mandates
• Two services (treatment and monitoring)
  were provided by a substantially higher
  percentage of sites where it was state
  mandated
          SUMMARY
• There is substantial variation in the % of
  programs offering the various services for
  a particular infection group
• There is consistency in the % of programs
  offering a particular service for all three
  infection groups
...And… THERE IS MORE DATA

								
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